-      THE 

UBERCULOSIS 
TURSE 


HER  FUNCTIONS  AND  HER  QUALIFICATIONS 


The 
Tuberculosis  Nurse 


Her  Function  and  Her  Qualifications 

A  Handbook  for  Practical  Workers  in  the  Tuber- 
culosis Campaign 


By 

Ellen  N.  La  Motte,  R.N. 

Graduate  of  Johns  Hopkins  Hospital  ;  Former   Nurse-in-Chief 

of  the  Tuberculosis  Division,  Health  Department 

of  Baltimore 


Introduction  by 
Louis  Hamman,  M.D. 

Physician    in    Charge    Phipps    Tuberculosis    Dispensary,  Johns 
Hopkins  University 


G.  P.  Putnam's  Sons 

New  York  and  London 
Imicfcerbocfter    press 
1915 


COPYRIGHT,   1915 

BY 
ELLEN    N.  LA    MOTTE 


Second  Impression 


Ube  Iknfcfeerbocfeer  ipress,  'ttew  ]JJorft 


tto 

MARY  E.  LENT 

MY  FRIEND 


358050 


INTRODUCTION 

'""TO  tuberculosis,  more  than  to  any  other  infec- 
*  tious  disease,  the  parable  of  the  seed  and  the 
soil  is  strictly  applicable.  Without  the  tubercle 
bacillus  there  can  be  no  tuberculosis,  but  for 
tuberculosis  to  develop,  many  factors  of  great 
complexity  and  as  yet  but  little  understood  must 
facilitate  the  implantation  of  the  bacillus  and 
augment  its  growth.  It  is  true  that  though  we  may 
emphasize  the  r61e  of  the  bacillus,  still  we  cannot 
completely  ignore  those  personal  factors  that 
contribute  to  make  the  infection  fruitful,  and  like- 
wise though  we  focus  our  attention  upon  individual 
resistance,  still  we  cannot  keep  out  of  sight  the 
invader  that  is  being  resisted.  The  two  viewpoints 
meet  and  run  together,  but  are  sufficiently  separate 
to  lead  to  different  methods  in  our  efforts  to  eradi- 
cate tuberculosis. 

On  the  one  hand  are  those  who  direct  their 
efforts  toward  the  annihilation  of  the  tubercle 
bacillus.  We  are  sufficiently  instructed  about  the 
life  history  and  habits  of  this  organism  to  lay  our 


vi  Introduction 

plans  upon  a  firm,  scientific  basis — a  basis  so  firm 
and  at  first  sight  so  simple  and  so  plausible  that 
over-enthusiasm  led  to  predictions  that  have  been 
sadly  disappointed.  The  principles  are  sound 
indeed,  but  in  practice  their  application  has  met 
with  insuperable  difficulties.  These  obstructions 
have  sharpened  our  wits  to  find  new  avenues  that 
now  promise  a  more  ready  approach  to  the  goal. 
To  put  the  matter  briefly,  the  tuberculosis  cam- 
paign of  the  past  fifteen  years  has  taught  us  two 
important  lessons:  first,  that  the  tuberculous 
cannot  be  isolated  in  their  homes;  second,  that 
they  cannot  be  cured  in  or  out  of  sanatoria.  I  am 
shocked  myself  to  read  these  bald  statements, 
particularly  the  second,  and  still  I  am  convinced 
that  they  are  true.  Some  patients  can  be  isolated 
in  their  homes,  and  many  patients  recover  from 
tuberculosis  and  remain  well.  Tuberculosis  is 
very  amenable  to  treatment  and  under  proper 
conditions  the  results  of  treatment  are  very 
gratifying.  The  difficulty  is  that  the  proper  con- 
ditions are  in  most  instances  wanting,  and  when 
they  are  absent  sanatorium  recovery  is  almost 
invariably  followed,  after  a  brief  period,  by  relapse. 
The  records  of  cases  with  tubercle  bacilli  in  the 
sputum  establish  this  fact.  Concerning  the  value 
of  statistics  of  cases  without  tubercle  bacilli  in  the 


Introduction  vii 

sputum  I  entertain  the  gravest  doubt.  While  I 
am  heartily  in  favour  of  treating  such  patients, 
the  personal  equation  enters  too  largely  into  the 
diagnosis  to  give  the  results  convincing  value  as 
evidence  of  the  lasting  benefits  of  treatment. 
Experience  has  taught  me  that  the  educational 
value  of  sanatoria  has  been  grossly  exaggerated, 
and  that  this  value  is  of  small  account  in  a  broad 
plan  of  prevention.  Our  present  knowledge, 
fortified  by  the  costly  experience  of  the  past  fifteen 
years,  forces  us  to  believe  that  the  most  direct 
and  effective  way  of  dealing  with  the  tubercle 
bacillus  is  to  isolate  as  many  advanced  consump- 
tives as  is  possible.  The  hospital,  perhaps  sup- 
pl^mented  by  colonies,  is  the  rational  method  of 
procedure.  Other  factors  are  of  importance;  all 
other  factors  are,  but  this  is  the  fundamental  and 
essential  factor  in  the  campaign. 

On  the  other  hand  are  those  who  direct  their 
efforts  towards  cultivating  the  soil.  Reliable 
studies  inform  us  that  ninety  per  cent,  of  the 
human  race  is  tuberculosis  infected,  and  that  infec- 
tion occurs  at  a  very  early  age,  so  that  at  twelve 
years  few  children  have  escaped  it.  Relatively  a 
small  number  of  those  infected  subsequently  be- 
come tuberculous,  so  that  something  more  than 
infection  is  necessary  for  tuberculosis  to  develop. 


viii  Introduction 

What  this  something  is  we  do  not  know.  Time, 
manner,  frequency,  and  intensity  of  infection  play 
an  important  part.  Apparently  too  there  is  a 
wide  personal  variation  in  susceptibility.  To  just 
what  this  personal  factor  is  due  we  are  not  in  a 
position  to  say,  but  certain  general  facts  known 
about  the  distribution  of  tuberculosis  afford  us  a 
clue  to  its  interpretation.  Tuberculosis,  like  most 
infectious  diseases,  thrives  under  the  conditions 
that  poverty  induces.  Inadequate  housing  facili- 
ties, insufficient  food,  filth,  and  sordid  care  are  a 
few  of  these.  If,  as  all  must  admit,  the  tubercle 
bacillus  is  more  or  less  ubiquitous  and  few  escape 
contact  with  it,  then  an  important  part  of  our 
campaign  of  prevention  will  be  the  raising  of 
personal  resistance  so  that  when  infection  occurs 
it  may  be  successfully  overcome.  Here  is  the  field 
for  wide  social  activity.  Everything  that  makes 
for  higher  standards  of  living  and  for  improved 
personal  hygiene  is  a  valuable  arm  against  tuber- 
culosis. Housing  laws,  child-labour  laws,  the  wage 
question,  municipal  recreation  centres,  the  liquor 
question,  social  service  in  all  its  departments,  vaca- 
tion lodges,  open-air  schools,  factory  inspection, 
and  so  on  and  so  on,  are  all  indirectly  valuable  anti- 
tuberculosis  agitation. 

It  is  not  my  purpose  to  discuss  the  relative 


Introduction  ix 

merits  of  the  various  phases  of  the  anti-tubercu- 
losis campaign.  The  death-rate  from  tuberculosis 
is  falling  steadily  and  rapidly,  and  it  has  fallen 
most  rapidly  in  just  those  centres  where  the 
campaign  has  been  vigorously  pushed  on  a  broad 
basis.  Which  phase  of  the  work  is  responsible  for 
the  decrease  or  deserves  the  greatest  credit,  it  is 
impossible  to  conclude  from  a  study  of  available 
evidence.  The  same  statistics  are  interpreted  by 
one,  for  instance  Cornet,  as  evidence  of  the  ef- 
ficiency of  sputum  prophylaxis;  by  another,  for 
instance  Hoffman,  as  evidence  of  the  influence  of 
improved  economic  conditions ;  by  yet  another,  for 
instance  Newsholme,  as  evidence  of  the  value  of 
hospitals  for  advanced  cases;  and  finally  by  many, 
for  instance  Frankel,  as  evidence  of  the  undisputed 
value  of  all  three  factors.  Which  factor  one 
emphasizes  will  depend  largely  upon  one's  training 
and  the  field  of  activity  in  which  one  is  engaged. 
Being  a  physician  and  by  training  accustomed 
to  view  problems  from  a  medical  standpoint,  it  is 
natural  that  I  should  emphasize  the  attacks  upon 
the  bacillus.  As  I  have  said,  it  seems  to  me  to  be 
firmly  established  that  the  most  efficient,  the  most 
direct,  and  the  cheapest  way  to  enforce  isolation 
and  prevent  infection  is  by  hospital  segregation  of 
cases  of  advanced  pulmonary  tuberculosis.  While 


x  Introduction 

early  diagnosis,  sanatorium  treatment,  and  educa- 
tion are  valuable  features  of  the  campaign,  their 
value  will  be  but  slight  if  this  one  essential  feature 
is  neglected.  Indeed  I  am  inclined  to  see  the  chief 
value  of  economic  improvement  in  the  indirect 
influence  this  improvement  exercises  upon  the 
facility  for  infection.  With  economic  advance  the 
aesthetic  value  of  general  and  personal  hygiene 
grows  apace,  and  the  dictates  of  ordinary  cleanli- 
ness offer  a  very  strong  barrier  to  infection.  Pov- 
erty itself  does  not  produce  tuberculosis,  but  the 
conditions  that  poverty  fosters  do,  and  the  ad- 
vantages of  better  living  reside  not  so  much  in  an 
improved  personal  fitness  as  in  the  eradication  of 
the  conditions  that  facilitate  infection.  This  view 
is  in  accord  with  what  we  have  learned  of  other 
infections.  Plague  has  been  notoriously  a  scourge 
to  the  poor.  To  improve  living  conditions  lessens 
plague,  and  this  general  fact  was  known  before  we 
learned  that  cleanliness  produced  results  indirectly 
by  eliminating  rats.  Malaria  has  always  been 
particularly  prevalent  amongst  labourers  living 
in  unprotected  huts.  To  improve  living  conditions 
reduces  malaria,  but  we  gain  the  result  more  surely 
and  directly  by  an  intelligent  campaign  against 
mosquitoes.  Unfortunately,  we  are  not  sufficient- 
ly instructed  about  tuberculosis  to  pick  out  of  the 


Introduction  xi 

whole  mass  of  ills  that  poverty  entails  those  few 
essential  features  that  control  infection.  Perhaps 
some  day  we  will,  and  then  we  shall  be  able  to 
manage  the  social  campaign  more  efficiently  and 
economically.  For  instance,  we  are  quite  at  sea 
to  know  what  prophylactic  use  to  make  of  the 
firmly  grounded  fact  that  tuberculosis  infection 
establishes  a  strong  resistance  to  reinfection. 
Upon  an  analogous  principle  rests  the  conquest  of 
smallpox  by  vaccination.  No  doubt  this  immunity 
reaction  has  an  important  influence  upon  the 
development  of  tuberculosis,  but  as  yet  we  know 
too  little  about  it  to  control  it  and  use  it  to  advan- 
tage in  our  fight  with  the  disease. 

In  the  anti-tuberculosis  campaign  the  nurse 
must  look  to  medical  science  for  the  plan  and 
inspiration  of  her  work.  Her  attitude  in  the  tuber- 
culosis campaign  must  always  conform  to  the 
medical  attitude,  although  she  may  and  indeed  has 
added  valuable  material  for  building  up  this  atti- 
tude. It  is  because  this  intimate  relation  exists 
that  I  have  briefly  outlined  the  medical  impression 
of  the  tuberculosis  campaign.  It  is  quite  natural 
that  it  should  represent  at  the  same  time  the 
nurse's  attitude.  My  object  was  to  point  out  the 
numerous  factors  concerned  in  the  anti-tubercu- 
losis crusade,  their  interrelation,  and  the  quite 


xii  Introduction 

natural  and  necessary  specialization  that  must 
occur.  The  field  of  the  nurse  and  particularly  the 
municipal  nurse  is  circumscribed,  but  it  is  large 
enough  to  engage  all  her  energy  and  devotion.  It 
is  not  necessary  nor  even  desirable  that  she  should 
diffuse  her  interest  and  energy  over  the  adjoining 
fields. 

For  more  than  ten  years  Miss  La  Motte  and  I 
have  been  engaged  in  working  at  the  same  prob- 
lems, from  the  same  broad  though  different  per- 
sonal viewpoint.  Our  work  has  brought  us  into 
almost  daily  contact.  I  acknowledge,  with  grati- 
tude, the  many  valuable  suggestions  that  I  have 
borrowed  from  her  experience,  and  in  reading  her 
book  I  note  with  the  greatest  satisfaction  what  I 
believe  to  be  evidence  of  influence  from  the  experi- 
ence I  have  gained.  It  is  a  pleasure  to  find  that 
after  years  of  arduous  work  we  agree  at  least  upon 
what  is  the  fundamental  problem  of  the  tubercu- 
losis campaign,  namely — institutional  care  of  the 
advanced  cases  of  pulmonary  tuberculosis.  I 
think  it  is  right  and  proper  that  Miss  La  Motte  has 
made  this  fact  the  guiding  principle  of  her  book, 
and  that  she  has  shown  the  relation  of  nursing 
activity  to  its  furtherance,  and  that  she  has  held 
all  other  phases  of  tuberculosis  work  subservient 
to  it.  To  avoid  misunderstanding  it  may  be 


Introduction  xiii 

necessary  to  point  out  that  other  features  of  the 
anti-tuberculosis  campaign  have  been  merely 
touched  upon  or  entirely  ignored.  This  apparent 
slight  is  not  offered,  I  am  sure,  as  a  reflection  upon 
the  value  of  these  features ;  they  are  omitted  simply 
to  accentuate  more  boldly  the  dominant  idea  of 
the  nurse's  work. 

Another  noteworthy  feature  of  the  book  is  the 
purely  personal  and  local  character  of  the  experi- 
ence presented.  It  details  the  problems  that  have 
offered  themselves  here  in  Baltimore,  how  these 
problems  have  been  met,  and  how  an  effective 
nursing  staff  has  been  built  up,  first  under  private 
and  then  under  municipal  control.  What  has 
been  accomplished  abroad  and  in  other  localities 
in  this  country  is  not  considered.  In  a  way  this  is 
a  disadvantage,  for  the  book  loses  somewhat  in 
breadth  and  erudition.  However,  I  am  convinced 
that  what  may  be  lost  in  this  respect  is  more  than 
compensated  for  by  the  gain  in  force  and  concise- 
ness. After  all,  the  fundamental  problems  are  the 
same  everywhere,  and  though  local  conditions  will 
necessitate  adjustment  of  details,  still  I  believe  the 
adjustment  will  be  stimulated  and  facilitated  more 
by  a  spirited  account  of  what  has  been  done  under 
specific  conditions  than  by  a  colourless  review  of 
the  whole  field  of  activity. 


xiv  Introduction 

No  doubt  many  will  find  personal  views  ex- 
pressed with  which  they  disagree.  This  is 
unavoidable  before  such  a  frank  and  radical  presen- 
tation of  the  situation.  One  is  impressed  by  the 
honesty  and  enthusiasm  of  the  book,  but  some  may 
wish  that  certain  of  the  statements,  and  particularly 
some  strictures,  had  been  a  little  mollified.  The 
book  will  be  interesting  and  helpful  and,  what  is 
more  important,  stimulating  to  all  engaged  in 
tuberculosis  work.  All  the  better  if  some  parts  of 
it  cause  surprise  and  opposition, — we  will  then 
review  more  critically  our  own  attitude. 

Louis  HAMMAN,  M.D., 
Physician-in-Charge,  Phipps  Tuberculosis 

Dispensary,  Johns  Hopkins  Hospital. 


PREFACE 

F^\URING  eight  successive  years  the  writer  has 
J— ^  been  engaged  in  special  tuberculosis  work, 
first  as  field  nurse  of  the  Visiting  Nurse  Association 
of  Baltimore,  later  as  organizer  and  director  of  the 
Tuberculosis  Division  of  the  Baltimore  Health 
Department.  Entering  the  field  in  the  pioneer 
days  of  1905,  she  has  seen  the  work  pass  through 
the  struggling  stages  of  private  enterprise  into  the 
well  organized,  almost  automatic  grooves  of  the 
city  machinery.  This  continuity  of  service  has 
been  an  experience  of  unique  value.  During  this 
period  we  have  walked  into  and  backed  out  of 
many  blind  alleys  or  "No  Thoroughfares,"  and 
have  acquired  wisdom  through  the  loss  of  infinite 
time,  effort,  and  money.  Although  the  material 
for  the  following  pages  was  gathered  in  Baltimore, 
and  is  therefore,  strictly  speaking,  of  a  local 
character,  yet  since  practically  all  of  the  conditions 
indicated  or  dealt  with  are  common  to  all  towns 
and  cities,  this  need  not  limit  the  application  of 
the  ideas  and  principles  set  forth. 

XV 


xvi  Preface 

It  is  also  hoped  that  though  the  work  of  tuber- 
culosis nursing  is  dealt  with  chiefly  as  done  under 
the  auspices  of  a  Visiting  Nurse  Association,  or  as 
part  of  the  work  of  a  City  Health  Department, 
what  is  here  presented  will  be  of  value  to  nurses 
working  under  private  associations,  and  to  private 
associations  themselves.  Therefore,  in  presenting 
this  book  to  the  public — to  nurses,  physicians, 
social  workers,  anti-tuberculosis  associations,  and 
all  those  engaged  in  public  health  work — the 
writer  has  two  objects  in  view.  First,  to  offer  a 
working  model  by  which  any  community  can  gain 
some  idea  as  to  how  to  organize  and  conduct 
tuberculosis  work;  second,  to  offer  conclusions, 
gained  through  practical  experience,  as  to  the 
nurse's  part  in  the  anti-tuberculosis  campaign. 

The  object  of  the  anti-tuberculosis  campaign  is 
the  eradication  of  tuberculosis.  Our  experience 
has  been  to  prove  that  the  simplest  and  most  direct 
method  of  controlling  this  disease  is  through  the 
segregation — the  voluntary  segregation — of  the 
distributor,  and  that  to  remove  the  patient  from 
an  environment  where  he  is  dangerous  to  one 
where  he  is  harmless  is  the  function  of  the  public 
health  nurse.  This  is  her  chief  and  foremost  duty, 
and  all  others  are  subsidiary  to  it. 

The  writer  wishes  to  express  her  appreciation 


Preface  xvii 

and  deep  indebtedness  to  those  friends  and  fellow 
workers  who  have  given  her  guidance  and  assist- 
ance during  these  years  of  service.  These  are: 
Mary  E.  Lent,  Superintendent  of  the  Visiting 
Nurse  Association  of  Baltimore,  and  Susan  Ed- 
mond  Coyle,  "lay  member"  of  that  Association; 
Dr.  Louis  Hamman,  Physician-in-Charge  of  the 
Phipps  Dispensary,  Johns  Hopkins  Hospital;  Dr. 
Samuel  Wolman,  First  Assistant  to  the  Phipps 
Tuberculosis  Dispensary;  Dr.  Gordon  Wilson, 
Physician-in-Charge  of  the  Maryland  University 
Dispensary  and  of  the  Municipal  Tuberculosis 
Hospital;  Dr.  Martin  F.  Sloan,  Superintendent 
of  Eudowood  Sanatorium;  Dr.  Victor  F.  Cullen, 
Superintendent  of  the  Maryland  Tuberculosis 
Sanatorium ;  and  my  Chief,  Dr.  Nathan  R.  Gorter, 
Health  Commissioner  of  Baltimore. 

ELLEN  N.  LA  MOTTE. 
London,  4  June,  1914. 


CONTENTS 
CHAPTER  I 

PAGE 

Statement  of  the  Case — Beginning  the  Work- 
Reaching  the  Patients — Supervision  of  the 
Work — Necessity  for  Experienced  Nurses  .  I 

CHAPTER  II 

The     Nurse's     Training — Health — Hours     Off 

Duty — Afternoons  Off — Character    .          .       n 

CHAPTER  III 

Salary — Increase  of  Salary — Carfare — Trans- 
portation —  Telephone  —  Vacation  —  Sick 
Leave — Uniforms — Badges  ...  20 

CHAPTER  IV 

Object  of  Work — Districts — Hours  on  Duty — 
Number  of  Daily  Visits— The  Nurse's  Office 
— Lunch  and  the  Noon  Hour — Bags — Pro- 
phylactic Supplies — Cups,  Fillers,  and 
Napkins — Disinfectant — Waterproof  Pock- 
ets— Books  of  Instruction — Stocking  the 
Bag  and  Distributing  Supplies — Nursing 
Supplies 33 


xx  Contents 


CHAPTER  V 

Records  and  Reports — The  Patient's  Chart — 
The  Card  Index— Nurse's  Daily  Report 
Sheet— Weekly  and  Monthly  Reports— Ex- 
amination of  Charts — Taking  the  Patient's 
History  ......  48 

CHAPTER  VI 

Finding  Patients  and  Building  up  the  Visiting 
List — Increasing  the  Visiting  List — Social 
Workers  —  Dispensaries  —  Patients'  Fami- 
lies and  Friends — Nurses'  Cases — Physi- 
cians .......  61 

CHAPTER  VII 

The  General  Practitioner  and  the  Public  Health 
— Responsibility  of  the  Private  Practitioner 
in  Tuberculosis — Impossibility  of  Fulfilling 
this  Obligation — Failure  because  of  the 
Nature  of  Tuberculosis — Failure  because 
of  the  Personal  Equation  ...  74 

CHAPTER  VIII 

The  Nurse  in  Relation  to  the  Physician — Mu- 
nicipal Control  of  Infectious  Diseases — The 
Nurse's  Difficulties — A  Waiting  Game — 
Undiagnosed  Cases — The  Nurse's  Responsi- 
bility to  the  Ethical  Practitioner  Only.  .  87 


Contents  xxi 


CHAPTER  IX 

Obtaining  a  Diagnosis — The  General  Dispen- 
sary— Sputum  Examinations — Tuberculin 
Tests — Registration  of  Cases  .  .  .105 

CHAPTER  X 

Prevention  of  Tuberculosis — Sources  through 
which  Calls  are  Received — Entering  the 
Home— Telling  the  Truth  to  the  Patient 
— Truth  for  the  Family — Disposal  of  Spu- 
tum— Danger  of  Expired  Air — Isolation  of 
Dishes — Linen,  Household  and  Personal — 
Disinfectant  and  Other  Supplies — Phthisi- 
phobia  .  .  .  .  .  .  .117 

CHAPTER  XI 

Inspection  of  the  House — The  Patient's  Bed- 
room— Porches — Gardens  and  Tents — Flat 
Roofs  —  Clothing  and  Bedclothing  —  Ar- 
tificial Heat — Rest — Fresh  Air — Food — 
Cooking— The  Bedridden  Patient  .  .136 

CHAPTER  XII 

Care  of  the  Family — Examination  of  the  Family 
— Taking  Patients  to  Dispensaries — Chil- 
dren— Tuberculosis  in  Children — Open-Air 
Schools — The  Danger  of  Sending  Patients 
to  the  Country  .  ,  ,  ,  -154 


xxii  Contents 


PAGE 

CHAPTER  XIII 

Disinfection  of  Houses — Value  of  Fumigation — 
Formaldehyde  —  Housecleaning  —  Burning 
and  Sterilizing — Boiling — Carpets,  Rugs, 
and  Mattings — Painting,  Papering,  and 
Whitewashing  —  Temporary  Removals  — 
Vacant  Houses — Concessions — Compulsory 
Cleaning .169 

CHAPTER  XIV 

The  Tuberculosis  Dispensary — Equipment — 
Medicines — Hours — Consideration  for  Pa- 
tients—  Function  of  the  Dispensary  — 
The  Physician's  Service — The  Physician's 
Qualifications — The  Physician  and  the  Pa- 
tient— Duties  of  the  Nurse — Tuberculin 
Classes — The  Nurse  in  Home  and  Dispen- 
sary— The  Nurse  as  a  Community  Asset  .  1 84 

CHAPTER  XV 

The  Nurse  in  Relation  to  the  Institution — Re- 
ports Made  to  the  Institution — Procuring 
Patients  for  it — The  Value  of  the  Sanator- 
ium— Sanatorium  Outfit — Return  from  the 
Sanatorium — Work  for  the  Arrested  Case 
—Light  Work — Outdoor  Work  .  .  203 

CHAPTER  XVI 

Hospitals    for    Advanced    Cases — The   Careful 

Consumptive — Chief  Duty  of  the  Nurse — 
Responsibility    of    the    Institution — Home 


Contents  xxiii 


Care  of  the  Advanced  Case — Exceptions 
to  Institutional  Care — Compulsory  Segre- 
gation .  .  .  .  .  .  .218 

CHAPTER  XVII 

The  Problem  of  Relief  Giving— The  Relief  Giver 
— Co-operation  between  Agent  and  Nurse 
— General  Rules  for  Nurses  and  Agents — 
Conditions  of  Asking  for  Relief — Wrong 
Conditions  erf  Relief  Giving  —  Incidental 
Assistance — Withdrawal  of  Relief  — Milk 
and  Eggs 230 

CHAPTER  XVIII 

Home  Occupations  of  Consumptives — Sewing 
and  Sweatshop  Work — Food — Milk  and 
Cream — Lunch  Rooms  and  Eating-Houses 
— Laundry  Work — Boarding  and  Lodging- 
Houses — Miscellaneous  Occupations  — The 
Consumptive  Outside  the  Home — Cooks — 
Personal  Contact  in  the  Factory — Super- 
vision Outside  the  Home  ....  252 

CHAPTER  XIX 

Municipal  Control  of  Tuberculosis — The  Danger 
of  "Political"  Control— " Politics"  in  Co- 
operating Divisions  of  the  Health  Depart- 
ment— Results  in  Baltimore — Tuberculo- 
sis and  Poverty  .....  273 


The    Tuberculosis    Nurse 


CHAPTER  I 

Statement  of  the  Case — Beginning  the  Work — Reaching  the 
Patients — Supervision  of  the  Work — Necessity  for  Experi- 
enced Nurses. 

Statement  of  the  Case.  Pulmonary  tubercu- 
losis is  a  communicable  disease,  transmitted  from 
person  to  person  by  means  of  the  tubercle  bacilli 
contained  in  the  sputum  of  infected  patients,  or 
in  the  breath  expired  during  paroxysms  of  cough- 
ing. The  bacilli  thus  liberated,  find  their  way 
into  the  system  of  another  individual,  either 
through  the  respiratory  or  alimentary  tract,  or 
both.  The  enormous  prevalence  of  tuberculosis 
is  due  to  the  fact  that  its  infectious  nature  was  not 
recognized  until  1882  when  Koch  discovered  the 
bacilli.  Since  that  time  it  has  been  classed  as  a 
transmissible  disease,  and  during  the  past  ten 
years  a  vigorous  effort  has  been  made  to  eradicate 
it.  This  agitation  is  popularly  known  as  the  anti- 


2  The  Tuberculosis  Nurse 

tuberculosis  campaign,  and  associations  for  the 
suppression  of  tuberculosis  have  sprung  up  in  all 
parts  of  the  country.  So  far,  no  serum  or  vaccine 
has  been  found  by  which  this  disease  may  be  con- 
trolled, as  was  the  case  when  smallpox  and  diph- 
theria were  checked.  The  sole  way  of  overcoming 
it  is  to  overcome  the  ignorance  concerning  its 
nature,  its  transmissibility,  and  the  means  by 
which  it  is  spread. 

At  the  beginning  of  the  campaign  it  was  believed 
that  simple  education  along  these  lines  was  all 
that  was  needed  to  obtain  results.  These  results 
were  expected  to  follow  as  soon  as  the  patient  was 
informed  of  the  nature  of  his  disease,  and  how  to 
avoid  spreading  it,  and  as  soon  as  those  in  contact 
with  him  were  given  like  information  and  taught 
how  to  avoid  infection.  Ten  years  ago,  in  the 
optimism  of  the  moment,  tuberculosis  was  freely 
proclaimed  a  "curable"  disease;  so  that  together 
with  the  campaign  of  prevention  went  a  campaign 
of  teaching  the  patient  how  to  become  a  "cured," 
or  as  we  now  call  it,  an  arrested,  case.  The  mechan- 
ics of  cure  were  equally  simple — rest,  fresh  air,  and 
food  were  all  that  was  needed,  provided  the  disease 
was  taken  in  the  early  stages.  And  all  that  was 
necessary  for  "cure, "  just  as  all  that  was  necessary 
for  prevention,  was  to  tell  the  patient  what  to  do, 


Statement  of  the  Case  3 

and  those  about  him  what  to  do,  and  the  thing 
was  done.  This  is  the  theory  upon  which  the  work 
was  founded,  and  in  theory  this  is  still  a  sound 
principle  upon  which  to  continue  it.  Unfor- 
tunately, a  series  of  unlocked  for  conditions  inter- 
posed themselves  between  this  theory  and  our 
ability  to  put  it  into  practice.  At  the  time  when 
the  crusade  was  begun  these  conditions  were  not 
recognized,  and  it  is  only  through  long  study  of  the 
situation,  from  its  social,  economic,  and  legal  as 
well  as  clinical  aspects  that  we  get  some  idea  of  the 
difficulties  and  complexities  of  the  task  before  us. 
In  the  first  place,  tuberculosis  is  largely  a  disease 
of  the  poor — of  those  on  or  below  the  poverty  line. 
We  must  further  realize  that  there  are  two  sorts 
of  poor  people — not  only  those  financially  handi- 
capped and  so  unable  to  control  their  environment, 
but  those  who  are  mentally  and  morally  poor,  and 
lack  intelligence,  will  power,  and  self-control.  The 
poor,  from  whatever  cause,  form  a  class  whose 
environment  is  difficult  to  alter.  And  we  must 
further  realize  that  these  patients  are  surrounded 
in  their  homes  by  people  of  their  own  kind — their 
families  and  friends — who  are  also  poor.  It  is  this 
fact  which  makes  the  task  so  difficult,  and  makes 
the  prevention  and  cure  of  a  preventable  and 
curable  disease  a  matter  of  the  utmost  complexity. 


4  The  Tuberculosis  Nurse 

People  of  this  sort,  however,  constitute  almost 
the  entire  problem — otherwise  the  situation  would 
be  so  simple  that  the  word  problem  would  not 
apply. 

This  is  why  "cure"  is  not  the  solution  of  the 
matter.  Too  few  people  are  cured,  in  comparison 
to  the  numbers  annually  infected,  to  make  any 
impression  on  a  disease  of  such  wide  prevalence. 
The  sanatorium,  valuable  as  it  may  be  for  certain 
cases,  is  of  little  use  to  those  who  relapse  upon 
return  to  an  environment  they  will  not  or  cannot 
control.  This  is  also  why  mere  instruction  in 
preventive  measures,  unaccompanied  by  effective 
isolation,  is  barren  of  results. 

Experience  has  taught  us  the  unsatisfactory 
nature  of  so-called  cures,  and  the  futility  of  that 
prevention  which  allows  the  distributor  of  tuber- 
culosis to  remain  at  large  in  the  community  and 
heedless  of  his  obligations.  Hence  we  must  look 
to  segregation  as  the  only  reasonable  course  to 
pursue.  If  segregation  can  be  obtained  in  the 
home,  well  and  good.  If  not,  then  we  must  look 
to  the  institution  to  provide  the  proper  care.  This 
segregation,  most  of  it  voluntary,  some  of  it 
enforced,  is  the  only  way  to  do  preventive  work  on 
a  scale  large  enough  to  count.  To  this  end,  we 
need  dispensaries  where  the  disease  may  be  recog- 


Beginning  the  Work  5 

nized  and  diagnosed,  nurses  to  visit  the  patients 
in  their  homes,  and  hospitals  for  advanced  cases, 
the  function  of  the  nurse  being  to  teach  patients 
and  their  families  the  necessity  for  segregating  the 
former  in  hospitals. 

Beginning  the  Work.  Let  us  suppose  that  a 
certain  community,  town  or  country,  suddenly 
becomes  aware  of  tuberculosis  in  its  midst,  and  in 
consequence  wishes  to  get  rid  of  it.  It  is  but  a 
fraction  of  the  community  which  is  enlightened 
enough  for  this,  but  from  this  nucleus  must  come 
all  that  awakening  of  public  sentiment  needed  to 
facilitate  the  campaign.  To  estimate  the  number 
of  tuberculous  persons  in  any  locality,  multiply 
the  yearly  tuberculosis  death-rate  by  five  or  ten — 
authorities  differ  as  to  the  exact  figures.  The 
result  will  be  the  approximate  number  of  those 
afflicted.  The  public  press  will  help  in  dissemi- 
nating this  information,  which  is  the  basis  from 
which  we  must  work.  Since  the  beginning  of 
the  campaign,  newspapers  have  been  wonderfully 
helpful  allies  in  giving  wide  publicity  to  facts 
concerning  tuberculosis.  As  a  result  of  this  newly 
aroused  interest,  an  Anti-Tuberculosis  Society 
may  be  created,  and  into  its  fold  are  gathered  all 
those  willing  to  help  in  the  work,  each  with  his 
dollar.  Lectures,  exhibits,  open-air  speaking, 


6  The  Tuberculosis  Nurse 

lantern-slide  exhibitions,  meetings  in  churches 
and  others  held  before  various  societies  are  given 
in  various  parts  of  the  town,  and  in  this  way  in- 
formation about  tuberculosis  is  spread  far  and 
wide. 

There  are  two  classes  of  the  community,  how- 
ever, that  must  be  reached' — those  who  have  tuber- 
culosis and  those  who  have  not.  The  people  who 
go  to  lectures  and  exhibits  belong  chiefly  to  the 
latter  class.  Frequently,  of  course,  the  sick  ones 
find  their  way  in,  in  an  endeavour  to  learn  some- 
thing which  may  be  helpful  to  them ;  unfortunate- 
ly, they  are  able  to  take  away  but  little,  and  the 
little  they  do  get  they  often  misapply.  We  recall 
the  case  of  a  man  who  went  to  a  tuberculosis 
exhibit,  and  learned  that  fresh  air  was  good.  As  a 
result,  he  walked  several  miles  a  day  in  order  to 
get  it,  and  nearly  killed  himself.  He  had  succeeded 
in  learning  one  important  fact — that  fresh  air  was 
valuable — but  another,  of  equal  importance,  that 
exercise  was  harmful,  had  escaped  him. 

To  make  the  undertaking  succeed,  it  is  necessary 
to  reach  both  the  sick  and  the  well,  since  that 
strong,  intelligent  public  opinion,  which  is  the 
motive  force  behind  all  new  movements,  must 
be  aroused  among  the  sick  as  well  as  among  the 
healthy.  But  as  we  have  seen,  the  former  are  not 


Supervision  of  Work  7 

those  who  go  largely  to  lectures,  so  they  must  be 
reached  through  some  other  means.  The  most 
effective  way  of  reaching  them  is  through  the  em- 
ployment of  a  special  nurse,  who  shall  give  eight 
hours  a  day,  week  in  and  week  out,  to  visiting  in 
the  homes  where  tuberculosis  exists,  and  giving 
instruction  adapted  to  each  individual  case.  By 
this  means  the  people  most  in  need  of  assistance 
are  reached  without  loss  of  time  and  effort,  and 
case  after  case  is  uncovered.  This  is  shooting 
straight  for  the  bull's-eye — namely,  the  infected 
home  from  which  tuberculosis  is  spread. 

There  may  be  laws  on  the  statute  books  com- 
pelling doctors  to  notify  the  local  health  authori- 
ties of  their  tuberculosis  cases,  but  these  laws  are 
not  lived  up  to.  Nor  will  the  establishment  of  a 
hospital  for  advanced  cases  bring  these  patients  to 
light;  neither  will  the  sanitorium,  nor  even  the 
special  tuberculosis  dispensary.  The  surest  and 
most  effective  way  of  unearthing  them  is  through 
the  visiting  nurse.  Therefore  the  nebulous  plans 
of  the  newly-formed  anti-tuberculosis  association 
may  well  crystallize  themselves  into  a  decision  to 
put  such  an  effective  agent  into  the  field. 

Supervision  of  Work.  After  this  decision  has 
been  made,  the  question  arises,  by  whom  is  the 
nurse  to  be  directed?  Is  she  to  be  placed  under 


8  The  Tuberculosis  Nurse 

the  local  health  department,  under  a  dispensary, 
under  the  charity  organization  society,  or  under 
the  visiting  nurse  association,  if  such  an  organiza- 
tion exists  in  the  town?  If  supported  by  a  church 
or  special  association  of  some  sort,  should  not  the 
governing  board  of  such  organization  direct  her 
work?  Or  is  she  to  be  a  free  lance  and  manage 
herself? 

Unless  taken  over  by  the  local  health  department 
(which  in  that  case  becomes  responsible  for  her 
salary  and  expenses  incurred  in  the  work),  the 
nurse  should  be  affiliated  with  the  Visiting  Nurse 
Association,  rather  than  with  any  lay  organization. 
Better  results  will  be  obtained  if  her  work  is 
directed  by  a  superintendent  of  nurses  who  is 
accustomed  to  dealing  with  and  judging  nurses, 
and  familiar  with  their  duties  along  technical 
lines.  The  credit  of  supporting  the  nurse  would 
still  rest  where  it  belonged — with  the  church,  with 
the  an ti- tuberculosis  association,  or  whatever 
group  of  people  might  be  responsible  for  her 
maintenance,  *  but  this  arrangement  would  relieve 
the  lay  organization  of  much  responsibility,  for  no 
matter  how  good  their  intentions,  such  a  group 

1  For  five  years  the  Maryland  Tuberculosis  Association  sup- 
ported five  nurses,  which  it  placed  under  the  management  of  the 
Superintendent  of  the  Visiting  Nurse  Association  of  Baltimore. 


Supervision  of  Work  9 

cannot  direct  nursing  work  as  well  as  this  can  be 
done  by  one  qualified  for  the  purpose.  Another 
advantage  gained  by  placing  the  new  nurse  with 
the  Visiting  Nurse  Association  is  that  it  keeps 
together  the  various  branches  of  public  health 
service,  and  the  tuberculosis  nurse  realizes  more 
fully  than  she  otherwise  might,  how  completely 
her  own  specialty  is  interlocked  with  and  depen- 
dent upon  other  forms  of  social  activity. 

There  is  still  another  advantage  in  placing  the 
new  nurse  with  the  established  organization,  for 
then  a  nurse  may  be  selected  with  regard  to  her 
ability  alone,  leaving  it  to  the  Superintendent  of 
Nurses  to  give  her  the  necessary  careful  training  in 
social  work,  and  the  proper  supervision. 

If  there  is  no  Visiting  Nurse  Association  in  the 
community,  under  whose  auspices  the  new  special 
nurse  may  be  placed,  the  lay  organization  will 
have  to  do  the  best  it  can.  In  this  event,  it  will 
be  absolutely  necessary  to  select  a  nurse  thoroughly 
trained  in  social  work,  and  since  the  number  of 
women  with  this  equipment  falls  far  short  of  the 
demand,  a  delay  of  some  duration  may  take  place. 
This  delay  is  always  borne  with  great  impatience 
by  the  newly  formed  group  of  people,  anxious  in 
their  enthusiasm  to  attack  the  tuberculosis  prob- 
lem at  once.  Yet  policy  would  counsel  postponing 


io  The  Tuberculosis  Nurse 

the  undertaking  until  a  suitable  person  can  be 
found,  for  it  is  usually  a  fatal  mistake  to  begin 
new  work  with  an  inexperienced  worker.  More- 
over, a  situation  which  has  existed  for  years  may 
be  tolerated  a  few  months  longer  without  undue 
alarm  as  to  consequences. 

If  it  is  impossible  to  obtain  a  nurse  fully  trained 
in  public  health  work,  the  community  may  select 
a  good  nurse  and  send  her  for  a  few  months*  ex- 
perience to  some  well  recognized  centre  of  public 
health  work,  such  as  New  York,  Chicago,  Boston, 
Baltimore,  etc.  The  money  thus  spent  will  prove 
a  valuable  investment  to  a  community  thus  far- 
seeing,  and  an  ample  return  will  be  manifest  in  the 
efficiency  of  the  nurse's  work. 

A  wrong  start  in  choosing  a  nurse  has  driven 
many  an  enthusiastic  organization  into  deep 
waters,  and  caused  trouble  and  misunderstanding 
of  a  most  grievous  sort.  In  several  instances,  the 
local  campaign  against  tuberculosis  has  come  to  a 
disappointed  end;  in  others,  public  interest  has 
been  so  antagonized  and  repelled  that  the  move- 
ment received  a  check  from  which  it  did  not  re- 
cover for  several  years. 


CHAPTER  II 

The  Nurse's  Training — Health — Hours  off  Duty — Afternoons  off 
— Character. 

Training.  One  of  the  first  qualifications  of  the 
nurse  should  be  proper  training.  She  should  be  a 
graduate  of  a  first-class  general  hospital,  which 
gives  a  three-years'  course.  In  States  where 
registration  is  established,  she  should  be  a  regis- 
tered nurse  as  well.  This  means  that  she  has 
passed  the  examinations  set  by  the  State  Board  of 
Examiners  for  Nurses,  and  has  attained  at  least 
the  minimum  degree  of  efficiency  prescribed  by 
that  body.  Of  course,  it  is  well  if  she  far  exceeds 
this  minimum,  but  she  must  not  fall  below  it  in 
any  case. 

It  is  sometimes  said  that  a  woman  trained  in  a 
sanatorium  or  special  tuberculosis  hospital  will 
make  as  good  a  tuberculosis  nurse  as  one  who  has 
been  trained  in  all  branches  of  nursing  work. 
This  claim  is  often  made  by  those  sanatoriums 
which  seek  to  find  positions  for  their  ex-patients, 
to  whom  they  have  given  a  more  or  less  sketchy 

ii 


12  The  Tuberculosis  Nurse 

training  and  a  diploma.  Needless  to  say,  if  a 
community  undertakes  to  support  a  nurse,  it 
should  procure  the  best  that  can  be  found.  There 
is  no  economy  in  employing  a  half -trained  woman. 
In  social  work  the  nurse  occupies  a  unique  position 
in  the  patient's  household — she  must  be  able  not 
only  to  gain  but  to  retain  the  family's  confidence, 
and  this  cannot  be  done  by  a  half -educated  woman, 
not  sure  of  herself  and  unable  to  carry  conviction 
to  her  hearers. 

Health.  Next  to  thorough  training,  the  health 
of  the  nurse  is  of  utmost  importance.  All  nurses 
should  be  examined  before  they  undertake  tu- 
berculosis work.  This  should  be  done  for  two 
reasons:  first,  for  the  obvious  reason  of  protecting 
the  nurse  herself;  secondly,  for  the  protection  of 
the  work.  There  is  already  sufficient  prejudice 
against  tuberculosis  work,  and  it  is  well  not  to 
increase  it  by  having  a  nurse  break  down  soon 
after  going  on  duty.  In  Baltimore,  all  applicants 
are  examined  by  a  specialist  before  they  are 
accepted.  Note  that  this  is  done  by  a  specialist, 
and  that  the  applicant  is  not  permitted  to  go  to 
her  own  "family  physician"  who  may  or  may  not 
be  able  to  make  a  proper  examination.  The 
candidate  is  given  a  choice  of  several  specialists, 
to  any  one  of  whom  she  may  go.  The  report  of 


Health  13 

her  physical  condition,  mailed  to  the  superin- 
tendent, determines  her  eligibility  from  the  stand- 
point of  health.  In  this  way,  the  responsibility  is 
assumed  by  those  most  capable  of  assuming  it,  and 
neither  the  health  of  the  nurse  nor  the  prestige  of 
the  work  is  jeopardized. 

After  the  preliminary  examination,  it  is  well 
for  the  nurse  on  duty  to  be  re-examined  every  six 
months.  If  suspicious  symptoms  present  them- 
selves, this  should  be  done  oftener.  Part  of  the 
superintendent's  duties  are  to  watch  the  health  of 
her  workers,  and  keep  a  sharp  look-out  for  sus- 
picious symptoms- — symptoms  which  the  nurse 
herself  may  be  unaware  of  or  afraid  to  acknow- 
ledge. Each  nurse,  however,  should  assume  the 
responsibility  for  her  own  health;  she  should  re- 
member that  she  is  dealing  with  a  highly  infectious 
disease,  and  that  it  behooves  her  to  keep  in  as  good 
physical  condition  as  possible.  Nurses  with  a 
predisposition  to  tuberculosis  should  not  undertake 
this  work. 

The  question  often  arises  as  to  whether  this 
visiting  work  is  suitable  employment  for  arrested 
cases — for  nurses  who  have  had  tuberculosis  and 
recovered.  It  is  not  suitable.  It  is  far  too  hard 
and  trying,  for  it  must  be  done  day  in  and  day  out, 
at  all  seasons  and  in  all  weathers,  and  involves 


14  The  Tuberculosis  Nurse 

severe  physical  strain.  For  that  reason  it  is  not 
proper  occupation  for  one  whose  health  is  in  any 
way  precarious.  The  danger  of  relapse  is  too  great. 
Nor  should  this  work  be  done  by  those  who  are 
afraid  of  tuberculosis.  If  fear  of  tuberculosis 
develops  after  a  nurse  goes  on  duty,  she  should 
be  released  at  once.  Under  such  circumstances 
she  cannot  do  good  work,  while  to  persuade  her  to 
remain  on  duty,  contrary  to  her  instincts,  is  a 
responsibility  too  grave  for  any  one  to  assume. 

Hours  off  Duty.  At  this  point  we  should  like 
to  speak  of  the  nurse's  hours  off  duty,  though 
strictly  speaking  they  are  not  within  our  scope. 
As  a  rule,  the  hours  on  duty  are  eight — from  9  A.M. 
till  5  P.M.,  with  an  hour  in  the  middle  of  the  day 
for  lunch.  This  is  a  long  day,  and  at  the  end  of  it, 
any  woman  is  in  a  condition  of  mental  and  physical 
fatigue.  The  constant  nervous  strain  occasioned 
by  contending  with  the  ignorance  and  stubborn- 
ness which  a  nurse  must  encounter,  is  particularly 
wearing. 

The  hours  off  duty  are  for  recuperation  from 
the  day's  toil,  and  if  this  recuperation  is  insuf- 
ficient, it  will  manifest  itself  in  various  ways.  A 
tired  nurse  is  of  no  use  as  a  teacher — she  cannot 
cope  successfully  with  the  obstinate  wills  of  her 
patients,  nor  with  the  trying  demands  of  the  daily 


Afternoons  Off  15 

routine.  Moreover,  a  physically  tired  person  is 
one  who  offers  ready  soil  for  the  development  of 
tuberculosis.  These  two  facts  must  be  constantly 
borne  in  mind.  Therefore  we  should  like  to  im- 
press upon  all  nurses  who  undertake  this  work  that 
they  must  take  excellent  care  of  themselves.  Rest, 
sleep,  and  food  are  the  three  essentials  to  good 
health,  and  any  scheme  of  life  which  reduces  these 
below  a  certain  level  is  bound  to  lead  to  disaster. 

No  one  condemns  reasonable  pleasures,  and  in 
no  other  work  is  relaxation  and  recreation  so  much 
required,  but  one  must  be  careful  not  to  burn  the 
candle  at  both  ends.  It  is  no  part  of  the  superin- 
tendent's duties  to  regulate  the  life  of  her  nurses 
outside  of  working  hours,  but  when  their  life  off 
duty  diminishes  their  working  ability,  she  is  then 
called  upon  to  interfere.  Tuberculosis  work  is 
trying,  serious,  and  difficult,  and  demands  a  high 
degree  of  mental  and  physical  strength  and  fresh- 
ness. If  a  nurse  is  not  willing  to  give  this,  she 
should  not  undertake  public  health  work. 

Afternoons  Off.  Each  nurse  should  be  given 
one  afternoon  a  week  off  duty.  It  is  more  satis- 
factory to  give  this  half -day  in  the  middle  of  the 
week,  on  Wednesday  or  Thursday,  rather  than  on 
Saturday,  at  the  week's  end.  In  this  way,  the  rest 
period  breaks  the  long  stretch  of  days,  and  the 


1 6  The  Tuberculosis  Nurse 

nurse  is  enabled  to  rest  before  she  becomes  too 
tired.  Sundays,  of  course,  should  always  be  free. 
Under  no  consideration  should  the  nurse  be  sub- 
ject to  night  calls  and  it  is  well  to  have  this  fact 
understood  at  the  outset  of  the  work.  A  nurse 
cannot  be  on  duty  night  and  day  both,  and  certain 
rules  should  be  established,  regarding  her  hours  on 
duty,  and  be  rigidly  adhered  to. 

Character.  The  questions  of  training  and  of 
health  having  been  satisfactorily  answered,  there 
remains  a  third  great  essential  to  be  considered — 
the  question  of  personality.  Social  nursing  differs 
from  all  other  branches  of  nursing,  since  in  this 
specialty  there  is  a  wider  departure  from  the 
routine  and  mechanical  duties  which  form  so  large 
a  part  of  nursing  work.  Those  qualities  which 
make  a  good  institutional,  or  a  good  private  nurse, 
do  not  necessarily  make  a  good  social  or  public 
health  nurse.  Something  more  is  demanded. 

Broadly  speaking,  apart  from  professional  train- 
ing, the  more  highly  educated  and  cultivated  the 
woman,  the  better  will  she  be  qualified.  This,  one 
may  say,  would  apply  to  all  branches  of  the  pro- 
fession, but  we  believe  these  qualities  are  more 
necessary  in  the  tuberculosis  nurse  than  in  the 
operating-room  nurse,  for  example.  The  latter 
does  work  which  demands  mechanical  quickness 


Character  17 

and  coolness;  the  former  requires  a  personality 
capable  of  dealing  with  human  beings  in  all 
stages  of  refractoriness,  over  whom  she  has  no 
authority,  but  from  whom  she  is  expected  to  ob- 
tain results.  As  every  one  knows,  it  is  far  easier 
to  deal  with  things  than  with  people. 

The  qualities  of  a  teacher  are  requisite.  No 
matter  how  well  one  may  know  a  subject,  if 'one 
cannot  present  it  clearly  and  impressively,  small 
progress  will  be  made.  Nor  is  it  the  patient  alone 
that  the  nurse  is  called  upon  to  deal  with.  Her  ac- 
tivities bring  her  into  close  relations  with  physi- 
cians, social  workers,  politicians,  boards  of  directors, 
and  "benevolent  individuals"  of  all  classes,  whose 
interest  and  good- will  it  is  necessary  to  secure.  She 
must  be  as  well  able  to  meet  people  of  this  sort,  as 
to  teach  the  humblest  patient  in  her  district. 

Since  this  is  social  work,  the  so-called  social 
virtues  are  a  necessity — and  these  exclude  a  bad 
temper  or  a  quarrelsome  disposition.  It  is  as 
essential  to  work  in  harmony  with  other  social 
workers  as  with  the  patients  themselves — the  two 
relationships  are  interdependent. 

Needless  to  say,  a  nurse  who  cannot  get  on  with 
her  patients  is  a  failure.  No  matter  how  experi- 
enced she  may  be,  or  how  well  trained,  if  she 
cannot  gain  the  confidence  and  friendship  of  her 


1 8  The  Tuberculosis  Nurse 

families  she  is  unfitted  to  deal  with  them.  It 
frequently  happens  that  for  the  first  few  visits  a 
family  may  be  uncordial  and  suspicious,  but  within 
a  short  time  a  well  trained,  sympathetic  nurse 
should  be  able  to  change  this  attitude  into  one  of 
confidence  and  appreciation.  A  few,  a  very  few 
families  remain  unchangeable  of  course,  but  their 
number  is  so  small  that  they  form  a  negligible 
quantity. 

Neither  should  a  nurse  fraternize  with  her  pa- 
tients. Through  familiarity  she  loses  the  personal 
dignity  which  means  so  much  to  her  authority. 
Authority  is  a  term  somewhat  subtle  in  its  defini- 
tion— it  means  that  hint  of  power,  of  sureness,  of 
knowledge,  which  enables  one  to  speak  with  a 
confidence  which  transmits  itself  to  others,  and 
compels  them  to  accept  one's  point  of  view.  A 
strong  personality  easily  conveys  this  sense  of 
authority,  but  it  may  also  be  conveyed  by  a 
personality  less  strong,  when  the  nurse  is  well  as- 
sured of  her  facts  and  cannot  be  caught  tripping. 
It  is  the  hall-mark  of  the  successful  teacher — this 
ability  to  impress  her  points  upon  others,  and  to 
make  them  see  that  what  she  proposes  is  right, 
reasonable,  and  advantageous. 

It  seems  hardly  necessary  to  speak  of  the  quali- 
ties of  honesty,  loyalty,  and  conscientiousness. 


Character  19 

When  they  are  lacking,  all  or  any  one  of  them,  the 
nurse  is  useless.  The  nurse  is  alone  in  her  district 
all  day  long,  from  early  morning  till  late  in  the 
afternoon,  and  she  must  be  a  woman  with  a  high 
sense  of  responsibility  and  worthy  of  her  trust. 
Patience,  that  despised  virtue,  is  also  an  essential 
part  of  the  nurse's  equipment,  for  she  must  listen 
to  long  details  of  illness,  and  must  be  willing  to 
reiterate,  over  and  over  again,  without  show  of 
annoyance,  the  rules  which  have  been  needlessly 
and  exasperatingly  ignored.  No  one  knows  better 
than  the  nurse  the  awful  hiatus  that  exists  be- 
tween preaching  and  practising- — the  glib  promise 
and  the  broken  pledge — but  she  must  never  show  her 
irritation.  We  have  known  many  excellent  nurses 
who  gave  up  this  work  because  they  could  not 
stand  discouragement  of  this  sort,  and  who  had  not 
vision  enough  to  look  into  the  future  for  results. 

This  standard  of  requirements  may  seem  high, 
but  it  is  not  impossible.  In  fact,  it  is  the  minimum 
from  which  successful  work  can  be  expected.  A 
superintendent  who  has  a  choice  of  nurses  will  of 
course  approximate  it  as  nearly  as  possible,  in 
choosing  her  staff.  The  higher  and  finer  the  type 
of  woman,  the  more  valuable  she  will  be — probably 
in  no  other  field  do  fine  instincts  and  fine  feeling 
tell  so  strongly. 


CHAPTER  III 

Salary — Increase     of     Salary — Carfare — Transportation — Tele- 
phone— Vacation — Sick  Leave — Uniforms — Badges. 

Salary.  A  good  nurse  should  command  a  good 
salary — she  is  worth  it.  There  is  a  tendency  to 
underpay  nurses  even  at  the  present  day,  because 
of  the  tradition  handed  down  from  the  Middle 
Ages,  that  nursing  service  should  be  given  largely 
as  a  matter  of  love  or  charity.  A  woman  who  gives 
up  her  whole  time  to  district  nursing,  doing  highly 
specialized  work,  should  at  the  very  least  receive 
a  living  wage.  Associations  are  often  asked  to 
supply  nurses  at  a  salary  of  forty  or  fifty  dollars  a 
month,  and  surprise  and  indignation  have  been 
expressed  because  such  a  woman  was  not  forth- 
coming. Salaries  should  be  large  enough  to  attract 
and  retain  efficient  women ;  a  small  salary  does  not 
attract  desirable  applicants,  as  a  rule,  and  this 
limits  the  field  of  selection.  Large  sums  are 
appropriated  for  hospitals,  sanatoriums,  dispen- 
saries, and  physicians'  services,  but  retrenchment 
takes  place  when  it  comes  to  the  nurse.  Her  work 
seems  to  be  the  one  point  where  economy  prevails. 

20 


Increase  of  Salary  21 

In  Baltimore,  the  staff  nurses  are  paid  seventy- 
five  dollars  a  month,  and  this  is  the  very  least  that 
any  woman  should  receive.  A  small  town  or 
country  community  would  doubtless  have  to  pay 
more  than  this,  especially  if  it  looks  to  the  city 
for  an  experienced  nurse.  The  reason  is  simple 
enough — other  things  being  equal  and  the  charac- 
ter of  work  the  same,  one  would  hardly  expect  a 
nurse  to  prefer  an  unknown  locality,  away  from 
home  and  friends,  unless  some  extra  inducement 
were  offered.  A  nurse  might  be  willing  to  organize 
work  in  a  small  city,  at  a  low  salary,  for  the  sake 
of  the  experience.  In  that  case,  it  is  the  experience 
which  offers  the  inducement.  This  once  gained, 
however,  she  would  shortly  be  in  a  position  to 
demand  more  salary  or  seek  a  wider  field  of  service. 

Increase  of  Salary.  The  question  constantly 
arises  whether  or  not  it  is  well  to  increase  the 
salary  of  the  staff  nurse  from  year  to  year.  If  she 
enters  the  work  at  seventy-five  dollars  a  month 
for  the  first  year,  is  it  well  to  increase  this  to  eighty 
dollars  a  month  for  the  second  year,  eighty-five 
dollars  the  third,  and  so  on  till  a  definite  maximum 
has  been  reached?  To  this  question  there  are  two 
answers. 

Undoubtedly  a  nurse  becomes  more  valuable  as 
her  experience  ripens.  Her  first  six  months  on 


22  The  Tuberculosis  Nurse 

duty  are  largely  spent  merely  in  acquiring  rudi- 
mentary knowledge  concerning  her  work.  As  she 
learns  to  know  her  district,  her  patients,  the  doc- 
tors, the  institutions,  the  social  workers,  her  value 
to  the  community  increases.  Each  succeeding 
year,  therefore,  which  increases  her  knowledge  of 
social  conditions,  should  make  her  in  so  far  more 
valuable.  It  would  seem  but  just,  under  these 
conditions,  that  her  remuneration  should  be  raised 
accordingly.  But  at  this  point  there  enters  a 
factor  which  we  must  recognize.  To  specialize 
in  tuberculosis  work  makes  peculiar  demands  upon 
one's  strength.  Quite  apart  from  the  physical 
strain,  which  is  always  great,  it  demands  the 
expenditure  of  a  vast  amount  of  nervous  force, 
required  in  the  constant  combat  with  opposition. 
For  this  reason  it  is  peculiarly  wearing  and  ex- 
hausting. Also,  by  its  nature,  it  tends  to  become 
monotonous.  These  two  factors — one  of  which 
tends  to  wear  out  the  individual,  the  other  to  make 
her  indifferent  and  stale — make  us  hesitate  to  say 
that  the  nurse's  value  keeps  increasing  year  after 
year.  It  undoubtedly  does  increase  up  to  a  certain 
point,  but  after  that  point  has  been  reached,  it 
tends  to  diminish.  Such  being  the  case,  the 
obligation  of  raising  the  salary  is  debatable. 

Two  kinds  of  nurses  are  usually  found  on  the 


Increase  of  Salary  23 

staff.  One  is  the  ambitious  nurse,  who  comes  for  the 
experience  and  training,  to  fit  herself  for  an  execu- 
tive position  elsewhere.  To  such  a  woman,  the 
routine  of  field  work  will  not  be  desirable  for  long — • 
not  for  more  than  a  year  or  two,  or  until  she  has 
gained  enough  experience  to  prepare  herself  for 
a  wider  field  of  service.  That  point  being  reached, 
her  executive  ability  will  seek  an  outlet  in  work 
where  she  herself  may  become  the  organizing 
and  directing  force.  To  such  a  nurse,  salary 
increase  will  offer  no  inducement,  since  she  will 
seek  that  increase  through  work  which  provides 
greater  opportunities  and  responsibilities. 

There  is  another  sort  of  nurse  on  the  staff 
however,  who  has  no  such  ambition;  no  executive 
ability,  no  desire  to  occupy  any  other  than  a 
subordinate  position.  This  one  will  never  venture 
into  a  position  of  responsibility,  such  as  her  experi- 
ence might  warrant,  but  prefers  instead  the  easier 
path,  choosing  to  be  guided  rather  than  to  guide. 
She  prefers  to  work  under  direction,  rather  than 
to  direct  others.  To  such,  an  increase  in  salary 
would  seem  but  a  just  reward  for  faithful  service. 
But,  as  we  have  said  before,  the  monotony  of 
tuberculosis  work  tends  to  produce  stale  workers. 
There  is  danger,  after  a  time,  that  the  first  alertness 
and  energy  may  wear  off,  the  nurse  may  settle 


24  The  Tuberculosis  Nurse 

down  into  a  rut,  and  her  daily  task,  though  faith- 
fully performed,  tends  to  become  one  of  mechanical 
routine. 

One  of  the  chief  duties  of  the  superintendent 
is  to  train  new  nurses,  and  she  should  renew  the 
personel  of  her  staff  whenever  the  welfare  of  the 
work  demands  a  change.  Sometimes,  when  a 
nurse  shows  flagging  energy  and  interest,  sufficient 
stimulus  may  be  given  by  removing  her  to  another 
district,  where  she  will  encounter  new  patients 
and  new  problems,  and  so  regain  her  old  keenness 
and  ability.  When  one  once  becomes  thoroughly 
tired  of  this  work,  however,  it  is  unwise  and  futile 
to  attempt  to  continue  it.  Therefore,  in  the 
interest  both  of  the  nurse  and  of  her  work,  it  does 
not  seem  wise  to  offer  inducements  for  prolonged 
service,  unless  the  individual  characteristics  of  any 
given  nurse  make  this  wholly  desirable. 

Carfare.  In  addition  to  salary,  a  reasonable 
sum  of  money  should  be  allowed  for  carfare.  This 
allowance  should  vary  in  accordance  with  the 
territory  to  be  covered,  those  nurses  who  visit  in 
smaller  areas  naturally  having  a  smaller  allowance 
for  the  purpose.  While  economy  in  this  matter  is 
always  necessary,  it  must  be  remembered  that 
undue  economy  in  carfare  is  wasteful  of  something 
still  more  important, — the  nurse's  time  and 


Transportation  25 

strength.  If  she  is  obliged  to  walk  long  distances 
between  cases,  this  will  greatly  reduce  the  number 
of  visits  she  can  make  in  a  day.  Moreover,  she  will 
spend  so  much  energy  in  mere  walking  that  she 
will  become  too  tired  for  effective  teaching.  Only 
fresh,  energetic  people  can  teach;  those  who  are 
physically  tired  are  apt  unconsciously  to  let  the 
obstinate  patient  have  his  own  way. 

Transportation.  In  small  towns  and  country 
districts  the  problem  of  transportation  is  often  a 
difficult  one.  There  are  either  no  street  cars,  or 
their  service  is  very  restricted  and  inadequate. 
Under  such  circumstances  it  will  be  necessary  to 
provide  the  nurse  with  a  horse  and  runabout, 
especially  if  she  is  expected  to  cover  a  large  terri- 
tory. Unless  there  is  proper  provision  for  trans- 
portation, it  will  be  impossible  for  her  to  visit  the 
patients  often  enough  to  make  any  impression,— 
her  teaching  will  be  laid  on  too  thin  to  have  much 
value.  And  to  depend  upon  haphazard,  volunteer 
offers  of  transportation  is  almost  as  bad  as  to 
expect  her  to  make  her  rounds  on  foot.  She  should 
be  given  proper  facilities  for  going  from  case  to 
case,  and  should  be  able  to  plan  a  day's  work  un- 
hampered by  any  considerations  as  to  if  or  how 
she  can  reach  her  patients. 

Telephone.     In  making  up  the  budget  of  neces- 


26  The  Tuberculosis  Nurse 

sary  expenses,  a  reasonable  sum  should  be  set 
aside  for  telephone  calls.  The  nurse  has  constant 
occasion  to  communicate  with  doctors,  institu- 
tions, social  workers,  and  so  forth,  and  this  item  of 
expense  should  not  come  out  of  her  own  pocket. 
A  careful  weekly  account  of  all  expenditures, 
including  telephone  calls  and  carfare  should  be 
rendered  by  her. 

Vacation.  A  vacation  of  at  least  one  month 
should  be  given  during  the  year.  Less  than  a 
month  is  not  sufficient  time  in  which  to  recover 
the  physical  and  nervous  energy  expended  during 
the  rest  of  the  year.  This  holiday  should  be  taken 
all  at  one  time,  rather  than  split  up  into  shorter 
vacations,  taken  at  intervals  throughout  the 
year.  We  all  know  that  a  week  or  two  is  not  suf- 
ficient time  in  which  to  restore  a  thoroughly 
tired  person;  at  the  end  of  such  a  short  period, 
one  is  just  beginning  to  feel  rested,  and  there  has 
been  no  margin  left  over  for  amusement,  which 
is  a  necessary  part  of  all  holidays. 

Strong  emphasis  must  be  laid  on  the  fact  that  if 
a  nurse  expects  to  return  to  her  work  and  continue 
it  successfully  for  another  year,  she  should  use  this 
vacation  as  a  means  of  fitting  herself  for  another 
year's  close  contact  with  an  infectious  disease. 
She  should  return  to  work  thoroughly  rested,  with 


Sick-Leave  27 

her  resistance  increased  by  rest  and  recreation,  not 
lowered  by  injudicious  use  of  this  time  off  duty. 

Sick-Leave.  While  a  nurse  is  supposed  to  be 
sufficiently  well  and  strong  to  go  on  duty  every 
day,  in  all  weathers  and  at  all  seasons  of  the  year, 
a  reasonable  allowance  for  illness  should  neverthe- 
less be  made.  Two  weeks'  annual  sick-leave  is  a 
good  allowance.  If  a  woman  is  off  duty  for  longer 
time  than  that,  needless  to  say  her  work  must 
suffer  and  her  patients  must  be  neglected.  If  a 
nurse  is  constantly  off  duty  for  small  ailments, 
this  shows  that  she  is  not  strong  enough  to  under- 
take this  arduous  work.  A  fixed  allowance  for 
sick-leave,  therefore,  will  tend  to  work  automatic- 
ally, and  will  eliminate  the  unfit,  whose  burden  of 
work  is  otherwise  added  to  that  of  the  steady 
working  members  of  the  staff. 

In  the  case  of  acute  illness,  such  as  typhoid 
fever  or  appendicitis,  it  would  be  perfectly  possible 
to  appoint  a  substitute  until  the  nurse  was  able 
to  resume  her  duties.  If  no  time  has  been  taken 
off  for  sick-leave  during  the  year,  the  two  weeks 
should  be  added  to  the  time  granted  for  vacation. 
If  exceeded  during  the  year,  the  salary  for  every 
day  thus  lost  should  be  deducted  from  the  monthly 
salary.  This  procedure  may  seem  harsh,  but  with 
a  large  staff  it  is  necessary.  It  places  a  double 


28  The  Tuberculosis  Nurse 

incentive  on  keeping  well,  and  nurses  who  would 
otherwise  have  been  thoughtless  and  careless  as  to 
their  health,  will  take  excellent  care  of  themselves, 
in  order  not  to  lose  one  day  of  their  coveted 
vacation. 

In  Baltimore,  the  municipality  gives  two  weeks' 
vacation,  and  two  weeks'  sick-leave.  If  the  sick- 
leave  is  unused,  a  reasonable  vacation  is  the 
result. 

Uniforms.  The  question  as  to  whether  or  not  a 
nurse  shall  wear  a  uniform  is  one  which  usually 
excites  much  discussion.  The  one  or  two  dis- 
advantages of  such  a  dress  are  more  than  offset 
by  the  numerous  reasons  in  its  favour.  Two  objec- 
tions are  usually  raised  to  wearing  it :  by  the  nurse, 
because  it  makes  her  conspicuous;  and  by  the 
patient,  because  the  uniform  makes  him  a  target 
for  neighbourly  gossip. 

Let  us  consider  the  first  objection,  that  made  by 
the  nurse.  A  nurse  does  not  feel  conspicuous  when 
on  duty  in  her  district.  Her  busy,  daily  routine, 
taking  her  in  and  out  of  homes  where  she  is 
needed,  soon  causes  her  to  forget  her  personal 
appearance.  A  self-conscious  woman  is  hardly  the 
right  sort  for  this  work.  The  only  rub  comes  when 
she  is  off  duty  and  going  to  and  from  her  district,  but 
this  cannot  be  held  to  constitute  a  serious  objection. 


Uniforms  29 

As  for  the  patient's  objection— he  would  be 
equally  conspicuous  if  regularly  visited  by  any 
woman  unknown  to  the  neighbourhood,  no  matter 
how  attired.  Prying  eyes  would  recognize  her  as 
an  alien,  and  the  neighbours  would  speculate  accord- 
ingly. We  have  often  heard  of  patients  who  for 
fear  of  what  the  neighbours  would  say  objected  to 
being  visited  by  agents  of  the  Charity  Organization 
Society.  Yet  the  agents  of  that  Organization 
wear  no  sort  of  uniform.  The  truth  is,  it  is  usually 
really  the  visit  itself  which  is  objected  to,  rather 
than  the  costume  of  the  visitor — the  costume 
merely  serving  as  an  excuse.  On  analysing  the 
objections  of  a  group  of  patients  who  disliked  the 
uniform,  they  were  found  to  be,  without  exception, 
patients  who  strongly  resented  every  suggestion 
made  to  them.  Their  one  desire  was  to  be  let 
alone,  to  be  as  careless  as  they  chose. 

On  the  other  hand,  the  advantages  of  the  uniform 
are  many.  In  the  first  place,  all  effective  care  given 
to  a  consumptive  has  to  include  nursing  as  well  as 
teaching.  Now,  one  can  "educate"  in  a  woollen 
dress,  but  one  certainly  cannot  give  bed-baths  in 
anything  but  a  cotton  dress,  which  can  be  plunged 
into  a  tub  and  washed.  And  whether  she  enters 
the  home  to  give  a  bed-bath,  or  whether  she  goes 
in  merely  to  distribute  prophylactic  supplies,  the 


30  The  Tuberculosis  Nurse 

fact  remains  that  a  nurse  spends  some  eight  hours 
a  day  in  contact  with  an  infectious  disease.  Good 
technique  demands  that  she  be  dressed  in  washable 
material. 

In  summer,  a  dress  of  washable  material  is  not 
conspicuous.  In  winter,  it  may  be  covered  with  a 
long  coat.  And  if  we  admit  that  such  a  dress  is 
necessary,  what  objection  can  there  be  to  making 
it  of  simple  and  uniform  design?  A  single  nurse  so 
arrayed  looks  neat  and  business-like;  a  staff  of 
nurses  looks  equally  so.  Moreover,  uniformity  of 
dress  suggests  uniformity  of  method,  standard, 
and  character  of  work,  and  hence  inspires  confi- 
dence. A  staff  of  nurses,  each  one  dressed  accord- 
ing to  the  hazard  of  her  own  fancy,  would  hardly 
create  the  same  impression. 

In  itself,  the  uniform  is  a  protection  to  its 
wearer.  It  enables  her  to  go  freely  and  without 
molestation  into  all  kinds  of  tenements  and  lodg- 
ing houses,  into  side  alleys  and  back  streets.  The 
well-known  dress  surrounds  her  with  recognition, 
affection,  and  respect. 

The  uniform  is  also  of  value  to  the1  patients  and 
to  their  friends.  It  enables  them  to  recognize  the 
nurse  as  she  passes,  and  to  call  upon  her  as  she 
goes  by. 

The  uniform  worn  in  Baltimore  consists  of  a 


Badges  31 

plain  shirtwaist  suit,  worn  with  white  linen  collar 
and  black  necktie.  The  dress  is  made  of  blue 
denim,  such  as  is  used  for  overalls.  Denim  of  this 
sort  has  two  sides,  a  light  and  a  dark;  the  dress  is 
made  up  with  the  light  side  out,  as  in  washing  it 
seems  to  "do  up"  better  than  the  darker  side. 
Black  sailor  hats  are  worn,  and  in  winter  long, 
dark  coats  protect  the  dresses.  This  uniform  is  not 
necessarily  the  last  word  as  to  what  a  uniform 
should  be,  but  it  is  simple  and  inexpensive,  and  the 
nurses  look  well  in  it. 

Badges.  The  staff  of  a  municipal  nursing  force 
is  usually  provided  with  badges  to  denote  that  they 
are  connected  with  the  Health  Department.  These 
badges  should  never  be  worn  conspicuously,  al- 
though they  should  be  readily  accessible.  They 
are  only  occasionally  needed,  however,  as  when 
entering  some  lodging  or  rooming  houses,  or 
houses  of  prostitution,  or  other  places  where  there 
may  be  marked  opposition.  To  show  them  when 
entering  a  private  home  would  be  bad  policy.  A 
nurse  usually  enters  a  private  house  as  a  friend, 
but  a  public  house  she  is  sometimes  obliged  to 
enter  in  her  official  capacity.  In  dealing  with  all 
her  patients,  however,  no  matter  where  they  are 
situated,  the  less  show  made  of  officialdom  the 
better.  By  the  time  her  patient  finds  out  that  she 


32  The  Tuberculosis  Nurse 

is  connected  with  the  Health  Department,  she 
should  be  already  firmly  established  as  his  friend, 
and  then  the  discovery  will  have  no  terrors. 
Indeed,  at  that  stage,  it  very  often  enhances  her 
value,  and  patients  often  feel  intense  pride  at 
being  visited  by  the  "city  nurse." 


CHAPTER  IV 

Object  of  Work — Districts — Hours  on  Duty — Number  of  Daily 
Visits — The  Nurse's  Office — Lunch  and  the  Noon  Hour — 
Bags — Prophylactic  Supplies — Cups,  Fillers,  and  Napkins — 
Disinfectant — Waterproof  Pockets — Books  of  Instruction 
— Stocking  the  Bag  and  Distributing  Supplies — Nursing 
Supplies. 

Object  of  Work.  The  object  of  tuberculosis 
nursing  is  the  home  supervision  of  all  persons 
suffering  from  pulmonary  tuberculosis.  This  super- 
vision should  include  patients  in  all  stages  of  the 
disease,  and  not  be  limited  to  those  who  are  in 
some  particular  stage,  such  as  early,  in  contradis- 
tinction to  advanced,  cases.  No  organization 
which  expects  to  do  effective  work  should  deal 
with  one  class  of  patients  alone,  since  the  bound- 
ary lines  between  the  different  stages  are  con- 
stantly shifting;  the  ambulatory  case  of  to-day 
may  be  the  bed-ridden  case  of  to-morrow,  and 
vice  versa,  and  any  attempt  to  limit  the  nurse 
to  one  class  or  the  other  would  mean  neglect  of 
both.  Unless  the  work  is  planned  on  such  inclu- 
sive lines,  it  will  be  necessary  to  place  a  second 
organization  in  the  field,  to  care  for  those  cases 
3  33 


34  The  Tuberculosis  Nurse 

which  have  been  thrown  out  by  the  first.  Policy 
of  this  sort  would  mean  a  number  of  similar 
organizations,  duplicating  and  overlapping  each 
other's  work  at  every  turn.  Thus,  in  the  same 
household,  we  should  see  the  early,  ambulatory 
patient  "advised"  by  the  nurse  of  one  organiza- 
tion, while  the  advanced,  bed-ridden,  more  in- 
fectious case  is  being  bathed  and  cared  for  by  the 
nurse  from  another.  Invidious  comparisons  would 
doubtless  be  made  by  the  family,  with  the  decision 
in  favour  of  '  'deeds,  not  words. ' '  True,  there  would 
be  co-operation  between  these  two  societies, — 
which  would  mean,  as  a  rule,  double  work,  duplica- 
tion of  visits,  endless  transferring  of  cases  back- 
wards and  forwards,  and  opening  and  closing  of 
records.  From  whatever  point  of  view  we  consider 
it,  this  is  a  very  poor  plan  of  work,  and  a  wasteful 
method.  The  nurse  should  be  in  a  position  to 
follow  the  fortunes  of  her  patients  for  months  and 
years.  Any  scheme  which  involves  transferring 
him  to  a  stranger,  from  an  old  friend  to  a  new,  at 
the  moment  when  he  slips  from  an  early  into  a 
most  infectious  stage,  is  to  lose  sight  of  him  and 
of  his  family  at  a  most  critical  time. 

Adequate  supervision  means  that  the  nurse 
must  teach,  nurse,  and  ferret  out  patients,  and  her 
patients  must  include  advanced,  early,  and  sus- 


Districts  35 

picious  cases.  The  care  should  be  of  two  kinds — 
instruction  as  to  the  nature  of  tuberculosis,  with 
general  teaching  along  the  lines  of  prevention  and 
prophylaxis;  as  well  as  actual  nursing  service, 
rendered  to  advanced  and  bed-ridden  cases.  The 
Baltimore  nurses  take  charge  of  all  tuberculous 
patients,  in  whatever  stage,  and  we  feel  that  this 
is  the  most  effective  way  to  carry  on  the  work. 

Districts.  A  small  town,  of  course,  constitutes 
but  one  district  in  itself.  A  larger  town  may  be 
divided  into  two  or  three  districts;  a  city,  into  as 
many  as  may  be  necessary.  The  principles  upon 
which  the  work  is  conducted  are  the  same  in  each 
case.  The  nurse  is  responsible  for  every  consump- 
tive in  her  district,  and  her  constant  endeavour 
should  be  to  bring  under  supervision  every  case  of 
tuberculosis  that  exists.  She  must  visit  all  pa- 
tients referred  to  her — give  them  instruction, 
prophylactic  supplies,  and  nursing  care;  unearth 
suspicious  cases  and  send  them  to  a  physician  for 
diagnosis ;  secure  hospital  or  sanatorium  treatment 
for  those  who  are  eligible,  and  arrange  all  details 
connected  with  their  admission.  To  accomplish 
these  duties,  she  must  know  the  physicians  of  her 
district,  the  dispensaries  and  institutions  where 
she  may  send  her  patients,  the  philanthropic  or 
relief -giving  agencies  whose  aid  is  so  often  needed, 


36  The  Tuberculosis  Nurse 

and  all  social  workers  whose  co-operation  is  neces- 
sary for  the  furtherance  of  the  work  in  hand. 

Hours  on  Duty.  Eight  hours  should  constitute 
the  working  day,  from  eight  or  nine  in  the  morning, 
till  'four  or  five  in  the  afternoon.  With  a  large 
staff,  the  day  will  probably  not  begin  till  9  A.M., 
while  a  single  nurse,  in  a  small  community,  may 
prefer  to  begin  earlier  and  so  finish  earlier,  es- 
pecially in  summer.  It  is  a  mistake  to  work 
overtime,  no  matter  how  interested  and  enthusi- 
astic one  may  be.  A  peculiarity  of  tuberculosis 
work  is  its  unending  character- — there  is  always 
more  to  do  than  can  be  crowded  into  the  longest 
day,  and  even  after  working  ten,  twelve,  fourteen 
hours,  one  would  always  feel  that  some  important 
thing  was  being  left  undone.  It  is  well  to  recog- 
nize this  fact  in  the  beginning,  although  the 
temptation  to  make  "just  one  more"  visit  is  often 
hard  to  resist.  The  nurse  who  habitually  works 
overtime  only  wears  herself  out  the  faster,  and 
in  the  end  her  patients  will  suffer  through  her  loss 
of  health  and  energy. 

Number  of  Daily  Visits.  This  is  a  variable 
factor,  and  depends  in  great  measure  upon  the 
size  of  the  district,  as  well  as  the  number  of 
patients  it  contains.  The  character  of  the  service 
rendered  also  determines  the  number  of  visits,  as 


Number  of  Daily  Visits  37 

new  patients  and  bed-ridden  patients  always  de- 
mand considerable  time.  If  a  nurse  calls  on  ten 
patients  in  a  block,  and  finds  none  of  them  in,  she 
naturally  can  make  more  visits  than  when  com- 
pelled to  spend  a  long  time  in  each  house.  As  in 
everything  else,  it  is  the  quality  that  counts, 
rather  than  the  quantity ;  the  day  which  shows  few 
visits  may  have  been  spent  more  profitably  than 
that  on  which  she  scored  a  high  total.  There  is  no 
general  rule  as  to  a  nurse's  capacity,  yet  it  is 
always  well  to  suspect  the  value  of  a  large  total  of 
daily  visits;  if  a  nurse  dashes  in  and  out  of  a  house, 
spending  but  a  few  moments  with  her  patients, 
she  has  probably  done  her  work  so  superficially 
that  nothing  has  been  accomplished. 

On  the  other  hand,  some  nurses  pay  far  too  few 
visits  because  they  have  no  head  for  planning  their 
work,  but  linger,  past  all  necessity,  over  unimpor- 
tant details.  To  judge  if  a  district  is  being  properly 
visited,  the  superintendent  should  know  the  dis- 
trict, and  she  should  also  know  her  nurse's  capac- 
ity. To  estimate  the  value  of  the  day's  work  by 
the  number  of  visits  alone,  is  like  those  societies 
who  reckon  their  value  by  the  number  of  pieces  of 
literature  they  distribute,  totally  regardless  as  to 
whether  any  of  it  bears  fruit. 

Roughly  speaking,  each  patient  should  be  visited 


38  The  Tuberculosis  Nurse 

once  a  week ;  failing  this,  once  every  ten  days  or  two 
weeks.  In  a  few  exceptional  instances,  this  time 
between  visits  may  be  still  further  extended,  but 
this  should  happen  only  when  the  patient  is  doing 
extremely  well,  following  all  the  rules,  and  giving 
efficient  and  intelligent  co-operation.  There  are 
not  many  patients  in  this  class — for  the  average, 
supervision  to  be  adequate  must  be  frequent. 

Very  ill  patients,  however,  must  be  seen  two  or 
three  times  a  week — every  day  would  not  be  too 
often,  did  the  work  permit.  Unfortunately,  if  the 
visiting  list  is  large,  these  sick  patients  can  be  vis- 
ited only  at  the  expense  of  other  cases  better  able 
to  take  care  of  themselves.  For  this  reason,  the 
visits  to  ambulatory  patients  may  become  as  in- 
frequent as  once  every  three  weeks.  If  the  visiting 
list  grows  so  large  that  these  infrequent  visits  are 
all  that  the  nurse  can  give,  then  her  instruction  is 
laid  on  so  thin  as  to  be  nearly  worthless,  a  con- 
dition of  affairs  which  calls  for  another  nurse. 

The  Nurse's  Office.  An  office  is  a  necessity 
for  the  nurse  as  a  place  where  she  may  keep  her 
nursing  and  prophylactic  supplies,  and  at  which 
she  will  report  at  certain  hours  of  the  day,  say  at 
9  A.M.,  at  lunch  time,  and  possibly  again  in  the 
afternoon  before  going  off  duty.  At  certain  speci- 
fied hours,  therefore,  it  will  be  possible  to  reach  her, 


The  Nurse's  Office  39 

either  in  person  or  by  telephone,  and  her  office 
hours  should  be  known  to  doctors,  social  workers, 
patients,  or  to  any  who  have  need  to  call  upon 
her.  In  a  small  town  or  country  district,  there  will 
of  course  be  only  one  office,  but  in  a  city  it  will  be 
necessary  to  have  several  branch  offices,  accessible 
to  the  nurses  of  the  different  districts.  These 
branch  offices  should  be  situated  on  the  border 
lines  of  two  or  three  adjoining  districts,  so  that  one 
office  may  be  used  in  common  by  several  nurses. 
In  a  city  there  is  also  the  central  office,  from  which 
the  superintendent  directs  the  work,  and  where 
the  staff  nurses  report  daily. 

In  Baltimore1  these  branch  offices  are  usually 
in  the  same  building  which  houses  a  branch  of  the 
Federated  Charities,  the  branch  office  of  the  Visit- 
ing Nurse  Association,  the  Infant  Welfare  Asso- 
ciation, and  other  similar  agencies.  In  this  way, 
the  various  social  workers  learn  to  know  each 
other,  and  to  secure  close  co-operation  and  under- 
standing. The  different  agencies,  however,  each 
have  their  separate  rooms  or  offices. 

The  nurse's  office  should  be  simply  but  com- 
fortably furnished.  It  is  used  for  several  purposes 
• — as  a  store  room  for  supplies,  and  as  a  rest  room, 

1  Baltimore  is  divided  into  sixteen  nursing  districts,  with  eight 
branch  offices  or  sub-stations,  for  the  use  of  the  sixteen  nurses. 


40  The  Tuberculosis  Nurse 

where  she  takes  her  lunch  and  spends  an  hour  off 
duty  in  the  middle  of  the  day.  The  furniture 
should  consist  of  a  large  writing  table,  which  may 
also  be  used  for  a  dining  table ;  chairs,  a  lounge  or 
couch,  and  a  small  gas  stove  or  Bunsen  burner  for 
cooking  simple  meals.  If  there  is  no  available 
closet,  there  will  have  to  be  a  commodious  cup- 
board for  storing  the  prophylactic  supplies.  A 
large  stock  of  these  must  always  be  kept  on  hand, 
so  that  the  nurse  may  refill  her  bag  before  starting 
out  again  on  her  afternoon  rounds.  A  telephone 
in  the  office,  or  at  least  in  the  same  building,  is  of 
course  necessary. 

Lunch  and  the  Noon  Hour.  It  is  not  within  the 
province  of  a  superintendent  to  dictate  to  her 
nurses  as  to  what  they  shall  eat.  The  association, 
be  it  private  or  municipal,  furnishes  the  office  and 
the  hour,  but  the  nurse  must  provide  her  own 
lunch  and  select  it  according  to  her  fancy.  A 
word,  however,  in  regard  to  this  lunch.  It  should 
be  as  nourishing  as  possible,  and  should  consist  of 
such  wholesome  food  as  eggs,  milk,  cocoa,  and  so 
forth.  If  a  nurse  substitutes  a  pint  of  milk  for  a 
cup  of  tea  or  coffee,  she  is  wise. 

In  addition  to  nourishing,  wholesome  food  (in 
contradistinction  to  unprofitable  pie  and  buns 
from  the  neighbouring  bakeshop),  a  short  period  of 


Bags  41 

relaxation  on  the  lounge  or  couch  is  a  wise  way 
in  which  to  spend  a  portion  of  the  noon  hour.  In 
dealing  with  tuberculosis,  food  and  rest  are  neces- 
sary to  keep  one  strong  and  well,  and  no  nurse  can 
afford  to  trifle  with  her  health  when  engaged  in 
this  serious  work.  On  no  account  should  the  noon 
hour  be  cut  short,  no  matter  how  little  tired  she 
may  be.  Better  work  can  be  done  if  one  is  well 
fed  and  rested. 

Bags.  The  association  which  employs  the  nurse 
should  also  provide  her  with  the  bag  for  carrying 
the  supplies.  The  kind  of  bag  needed  is  a  much 
discussed  question.  It  should  be  strong,  even 
though  this  necessitates  its  being  heavy.  There  is 
no  other  way  out  of  it — for  unless  the  bag  has  the 
first  qualification,  strength,  the  weight  of  the 
supplies  will  soon  wear  it  out.  Very  light  bags  are 
not  practical. 

The  bags  used  in  Baltimore  are  made  somewhat 
like  the  ordinary  Boston  bag,  about  fourteen 
inches  long,  and  of  good  black  leather.  They  weigh 
a  few  more  ounces  than  those  used  by  other 
associations,  but  they  last  longer.  It  must  also  be 
remembered  that  the  bag  used  by  the  tuberculosis 
nurse,  no  matter  how  heavy  it  is  when  she  starts 
forth  on  her  rounds,  grows  lighter  and  lighter  as 
she  goes  from  house  to  house,  leaving  the  supplies. 


42  The  Tuberculosis  Nurse 

Thus,  at  the  end  of  the  day,  when  she  is  most 
tired,  it  is  practically  empty. 

Prophylactic  Supplies.  The  prophylactic  sup- 
plies used  for  the  patients  consist  of  tin  sputum 
cups,  cardboard  fillers,  paper  napkins,  water- 
proof pockets,  disinfectant,  and  books  of  instruc- 
tion. The  first  three  are  of  primary  importance. 
The  Health  Department  of  a  community  usually 
provides  these  supplies,  even  when  the  nursing 
work  is  carried  on  by  a  private  association.  Thus, 
in  Baltimore,  where  for  six  years  the  tuberculosis 
work  was  done  by  the  Visiting  Nurse  Association, 
an  arrangement  was  entered  into  between  this 
Association  and  the  State  Board  of  Health,  ac- 
cording to  which,  the  latter  paid  for  and  provided 
the  supplies  which  the  nurses  distributed.  The 
only  condition  imposed  was  that  each  case  should 
be  reported  to  the  Health  Department,  and  that 
the  Health  Department  should  be  constantly  ad- 
vised as  to  the  number  of  cases  under  supervision. 
If  no  such  arrangement  is  possible,  then  the 
private  association  supporting  the  nurse  must 
be  put  to  the  additional  expense  of  buying  the 
supplies. 

It  is  impossible  to  make  the  patients  themselves 
pay  for  them.  Naturally,  they  consider  them  a 
nuisance  and  a  bother,  and  it  is  difficult  enough  to 


Disinfectant  43 

persuade  them  to  use  them,  even  when  given  free. 
The  cost  is  not  great,  however. 


Tin  sputum  cups,  (in  lots  of  5000) 7  cents  apiece. 

Fillers,  (in  lots  of  1,000,000) $3.50  per  thousand 

Paper  napkins,  (in  lots  of  5,000,000) $.55  per  thousand. 

Disinfectant, 10  cents  a  bottle. 

Waterproof  pockets 4  cents  apiece. 

Books  of  instruction 2  or  3  cents  apiece. 


Disinfectant.  The  most  expensive  of  the  sup- 
plies is  the  disinfectant,  which  is  also  probably  the 
least  valuable.  That  used  in  Baltimore  is  a 
special  preparation,  consisting  largely  of  creolin; 
it  is  put  up  in  pint  bottles  by  one  of  the  large 
wholesale  drug  houses.  For  use,  it  is  diluted  in 
water,  a  tablespoonful  to  a  pint,  and  used  in  wip- 
ing up  floors,  furniture,  and  so  forth.  It  is 
of  necessity  too  dilute  to  have  much  germici- 
dal  action,  and  the  patients  place  far  too  much 
reliance  upon  its  odor — which,  to  the  ignorant 
mind,  is  of  prime  importance.  Although  we 
use  this  disinfectant,  we  prefer  to  teach  our  pa- 
tients that  better  results  may  be  obtained  by  the 
lavish  use  of  hot  water,  brown  soap,  and  a  scrub- 
bing brush,  and  that  thorough  cleaning  of  this 
kind  is  of  more  value  than  the  most  malodorous 
drug  ever  dispensed.  Disinfectant  to  be  of  real  use 
must  be  strong  and  powerful,  and  it  is  dangerous 


44  The  Tuberculosis  Nurse 

to  distribute  such  powerful  drugs  promiscuously. 
Several  of  our  patients  have  tried  to  commit 
suicide  by  drinking  even  the  weak  preparation 
that  we  gave  them.  On  the  whole,  we  believe 
that  an  anti-tuberculosis  society  would  lose  no- 
thing by  omitting  disinfectant  from  its  list  of 
prophylactic  supplies,  and  better  results  could  be 
obtained  by  substituting  a  thorough  grounding  as 
to  the  value  of  soap  and  water. 

Waterproof  Pockets.  These  are  little  calico 
bags,  dipped  in  paraffin,  or  some  similar  prepara- 
tion which  makes  them  fairly  waterproof.  These 
are  pinned  inside  the  coat  pocket,  and  the  patient 
uses  them  as  a  receptacle  for  his  soiled  napkins, 
when  he  is  out  on  the  street,  or  in  other  places 
where  he  cannot  carry  his  sputum  cup.  The 
napkins  are  burned  upon  his  return. 

Books  of  Instruction.  These  little  books  are 
more  or  less  valuable,  but  are  by  no  means  in- 
tended to  take  the  place  of  the  verbal  instruction 
which  it  is  the  nurse's  duty  to  give.  They  serve 
merely  to  refresh  the  memory  after  she  has  gone. 
They  can  be  procured  at  small  cost  through  the 
various  anti-tuberculosis  organizations,  and  most 
Boards  of  Health  print  them  for  their  own  dis- 
tribution. The  best  of  them  are  inadequate. 

Stocking  the  Bag  and   Distributing  Supplies. 


Prophylactic  Supplies  45 

When  the  nurse  starts  forth  on  her  morning  rounds, 
her  bag  should  contain  enough  supplies  for  the 
patients  she  proposes  to  call  on.  Each  should  be 
given  enough  to  last  until  her  next  arrival.  It  is 
sometimes  possible  to  direct  either  the  patient 
himself,  or  some  member  of  his  family,  to  come  to 
the  office  and  get  a  fresh  stock  whenever  necessary. 
By  putting  this  slight  responsibility  on  the  fam- 
ily, it  is  made  to  realize  how  necessary  are 
these  supplies,  but  it  should  not  relieve  the  nurse 
of  her  obligation  to  visit  such  a  household,  and 
keep  it  under  as  close  observation  as  any  other 
case.  If  a  nurse  thus  trains  a  certain  number  of 
patients  to  come  themselves  for  the  supplies,  she 
will  be  able  to  reserve  the  contents  of  her  satchel 
for  those  patients  who  cannot  call  for  them,  or 
who  are  too  indifferent  to  do  so. 

Supplies  should  always  be  given  out  freely,  and 
the  patient  should  not  feel  that  he  is  put  under  any 
obligation  by  accepting  them.  They  are  intended 
for  his  personal  use  and  convenience,  and  he  should 
be  made  to  realize  this.  Otherwise,  some  patients 
may  hesitate  to  accept  all  that  they  really  need. 
If  a  patient  needs  four  or  five  fillers  a  day,  he 
should  unquestionably  have  them — otherwise  he 
may  practise  small  economies  which  will  mean 
unnecessary  exposure  for  his  family.  On  the 


46  The  Tuberculosis  Nurse 

other  hand,  the  nurse  must  see  that  the  supplies  are 
used  for  the  purpose  intended — we  have  some- 
times known  handkerchiefs  used  as  a  decoration 
for  kitchen  shelves,  simply  because  the  nurse  had 
given  away  far  more  than  was  necessary. 

Nursing  Supplies.  In  addition  to  the  prophy- 
lactic supplies,  the  bag  also  contains  a  number  of 
articles  used  in  caring  for  bedridden  or  very  ill 
cases.  Naturally,  these  articles  are  not  given  to 
the  patients,  but  are  used  from  case  to  case,  as 
necessity  arises.  They  include  a  bottle  of  alcohol, 
boracic  ointment,  talcum  powder,  gauze,  adhesive 
strapping,  absorbent  cotton,  and  a  thermometer. 
The  nurse  should  always  carry  an  apron,  to  be 
worn  when  doing  any  nursing  work. 

The  most  common  dressing  is  that  of  bedsores; 
many  patients  with  pleurisy  have  to  be  strapped; 
others  have  drainage  tubes,  which  must  be  taken 
out  and  cleaned.  These  extensive  dressings  are  not 
those  which  the  nurse  should  properly  be  required 
to  attend  to,  since  a  patient  ill  enough  to  require 
an  extensive  dressing,  is  a  patient  who  should  be 
sent  to  a  hospital.  Hospital  accommodation,  how- 
ever, is  unfortunately  very  limited,  and  the  nurse 
is  often  obliged  to  do  these  dressings  while  waiting 
for  a  vacancy  to  occur.  It  is  no  part  of  the  pro- 
gramme to  keep  these  advanced  cases  at  home 


Nursing  Supplies  47 

rather  than  in  an  institution ;  on  the  contrary,  the 
nurse  must  make  every  effort  to  get  them  away— 
but  until  this  can  be  accomplished,  it  is  her  duty  to 
care  for  them  at  home. 


CHAPTER  V 

Records  and  Reports — The  Patient's  Chart — Closing  the  Chart 
—The  Card  Index— Nurse's  Daily  Report  Sheet— Weekly 
and  Monthly  Reports — Examination  of  Charts. 

Records  and  Reports.  Every  association, 
whether  it  be  private  or  municipal,  supporting  one 
nurse  or  fifty,  should  keep  careful  records  concern- 
ing its  patients,  and  concerning  its  nurses'  work. 
These  two  sets  of  records  should  dovetail  and  form 
a  cross  file;  by  looking  at  the  patient's  chart,  one 
should  be  able  to  note  the  condition  of  each  indi- 
vidual case,  and  how  often  and  on  what  dates  he 
was  visited.  By  looking  at  the  nurse's  record,  one 
should  be  able  to  know  exactly  how  she  had  em- 
ployed every  moment  of  her  day,  and  to  see  the 
number  of  patients  she  had  visited  during  the  course 
of  it.  The  patients'  charts  account  for  the  pa- 
tients— the  nurse's  daily  report  accounts  for  her 
work  among  them. 

The  Patient's  Chart.  Each  patient  should  have 
a  chart  made  out  for  him  at  the  moment  when  he  is 
taken  on  the  visiting  list.  This  also  applies  to  sus- 

48 


The  Patient's  Chart  49 

pects,  or  those  for  whom  the  diagnosis  is  not  pos- 
itive, but  whom  the  nurse  is  required  to  visit 
and  care  for.  This  also  applies  to  those  moribund 
patients,  who  may  live  but  a  few  hours  after  being 
reported,  and  who  die  before  a  second  visit  can  be 
made.  Whether  he  has  been  on  the  list  a  year  or 
an  hour,  it  is  necessary  to  account  for  every  patient 
who  passes  under  supervision,  and  to  record  the 
result  in  each  case.  Unless  this  is  done,  accurately 
and  promptly,  it  will  be  impossible  to  estimate  the 
amount  of  work,  and  its  value  to  the  community. 
The  patient's  chart  should  contain  name,  sex, 
age,  colour,  address,  occupation,  social  status 
(married,  single,  or  widowed),  and  a  brief  history 
concerning  the  onset  and  progress  of  his  disease. 
These  charts  may  be  as  simple  or  as  elaborate  as 
one  desires.  Herewith  is  submitted  a  specimen 
chart,  such  as  are  used  in  Baltimore;  they  are  not 
perfect,  nor  the  acme  of  all  that  is  or  might  be 
desirable  in  a  record  of  this  kind,  but  they  have 
proved  simple  and  fairly  satisfactory.  There  is 
much  left  out  which  with  advantage  might  have 
been  added,  but  in  this  connection  it  is  well  to 
remember  that  an  elaborate  and  exhaustive  his- 
tory, one  demanding  dozens  of  intimate  details, 
is  apt  to  alarm  the  patient  excessively.  To  collect 
exhaustive  statistics  would  be  valuable  for  the 

4 


The  Tuberculosis  Nurse 


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52  The  Tuberculosis  Nurse 

sociologist,  but  to  do  so  at  the  expense  of  the 
patients'  confidence  and  trust  would  be  to  defeat 
the  object  of  the  work  itself. 

The  reverse  side  of  this  chart  contains  spaces 
in  which  each  visit  may  be  recorded.  Sometimes 
these  charts  are  kept  up  for  months  and  years,  and 
it  is  therefore  necessary  to  have  what  are  called 
second  sheets — alike  on  both  sides,  and  resembling 
the  reverse  side  of  the  first  sheet,  which  contains 
the  patient's  history.  These  sheets  are  fastened 
together,  and  the  chart  of  a  chronic  case  may  thus 
record  hundreds  of  visits.  Each  nurse  is  responsible 
for  keeping  up  the  charts  of  all  patients  under  her 
supervision.  The  notes  should  be  carefully  re- 
corded at  the  end  of  each  day's  work,  for  it  is  bad 
policy  to  let  this  charting  accumulate  for  even 
two  or  three  days.  The  entries  should  be  brief 
and  concise,  and  should  describe  the  patient's  con- 
dition, or  the  work  done  for  him. 

Each  nurse  should  have  a  filing  box  or  drawer 
in  which  to  keep  these  charts;  they  should  be 
arranged  in  alphabetical  order,  and  kept  at  the 
central  office,  where  the  superintendent  may  have 
ready  access  to  them.  These  charts  are  the  prop- 
erty of  the  association,  and  under  no  circumstances 
are  to  be  removed  from  the  central  office.  The 
nurse  may  make  her  entries  upon  them  either  at 


The  Card  Index  53 

the  end  of  the  day's  work,  or  before  she  goes  on 
duty  the  next  morning. 

Closing  the  Chart.  Patients  are  removed  from 
the  visiting  list  when  they  die,  or  when  they  are 
discharged.  They  are  discharged  only  for  one  of 
three  reasons — either  they  leave  the  city,  or  they 
move  and  their  address  is  lost,  or  they  prove  not 
to  be  tuberculous.  When  a  patient  dies  or  is  dis- 
charged, a  suitable  entry  is  made  on  his  chart, 
which  is  then  turned  in  to  the  superintendent  of 
nurses,  or  to  whomever  is  responsible  for  the  records. 
If  there  is  only  one  nurse,  it  is  of  course  her  duty 
to  file  these  closed  histories.  These  records  should 
be  rich  mines  of  sociological  information,  and 
should  contain  valuable  material  for  those  who 
have  access  to  them,  such  as  municipal  authorities, 
physicians,  and  social  workers.  Except  for  the 
access  allowed  to  these,  the  files  should  be  con- 
fidential. 

The  Card  Index.  All  offices  should  contain  a 
card  index,  giving  the  name -and  address  of  each 
patient  under  supervision.  Change  of  address 
should  always  be  noted,  since  it  is  only  by  means 
of  this  card  index  that  the  particular  chart  desired 
can  be  referred  to.  For  example:  the  card  index 
contains  the  names  of  some  3000  cases,  all  under 
supervision,  and  each  one  having  its  own  chart. 


54  The  Tuberculosis  Nurse 

The  charts  themselves,  however,  are  distributed 
among  the  filing  boxes  of  several  nurses.  If  particu- 
lars are  wanted  concerning  John  Doe,  it  would  be 
necessary  to  turn  first  to  the  card  index,  find  his 
address  and  the  district  in  which  he  lives,  and  then 
turn  to  the  filing  box  of  that  district  and  take  out 
the  chart.  If  it  were  not  for  the  card  index,  it 


TUBERCULOSIS  DIVISION. 


Name , Color 

Address : ^ . 

First  Visit Last  Visit Total 

Condition 


Reported  ky                                          Occupation 
M.  D. 


Card,  three  by  five  inches,  used  in  Card  Index 

would  be  necessary  to  search  through  all  the  filing 
boxes  before  finding  the  desired  chart. 

As  the  discharged  charts  are  handed  in,  the 
corresponding  card  in  the  index  is  withdrawn  and 
filed  away  in  a  drawer  containing  either  the  dead 
or  the  discharged  cases  according  to  circumstances. 
This  is  a  very  simple  way  of  keeping  rcords,  and  of 
balancing  from  day  to  day  the  number  of  patients 
on  the  visiting  list.  This  balance  may  be  made 


Nurse's  Daily  Report  Sheet        55 

every  week  or  every  month,  as  desired,  for  it  is  a 
simple  method  and  reduces  to  a  minimum  the 
opportunities  for  mistakes  in  addition  and  sub- 
traction. Needless  to  say,  no  one  but  the  super- 
intendent or  her  secretary  should  have  access  to, 
or  touch  these  files  in  any  way. 

Nurse's  Daily  Report  Sheet.  Beside  the  pa- 
tients' charts,  the  nurse  must  fill  in  a  day  sheet,  or 
daily  report  of  her  work,  to  be  handed  to  the  super- 
intendent, or  to  whomever  she  is  responsible. 
This  sheet  accounts  for  her  time  and  occupation 
all  through  the  day.  Beginning  with  the  time  she 
goes  on  duty  in  the  morning,  she  will  record  each 
visit  to  each  patient,  the  service  rendered,  and  the 
time  spent  on  him.  She  will  also  record  the  time 
she  reached  her  office  for  lunch,  and  the  time  she 
left  it  for  her  afternoon  rounds,  also  the  hour  at 
which  she  went  off  duty  for  the  day.  A  record  of 
this  kind  means  additional  clerical  work,  but  how 
else  is  the  nurse  to  account  for  her  day?  And  be  it 
noted,  it  is  always  a  satisfaction  to  the  nurse  to 
place  on  record  the  summary  of  her  day's  work. 

This  daily  report  sheet  is  of  great  value  to  the 
superintendent:  without  it,  there  is  no  way  in 
which  she  can  estimate  either  the  quality  or  the 
quantity  of  each  nurse's  work.  A  glance  at  the 
report  will  show  whether  the  day  has  been  light  or 


56  The  Tuberculosis  Nurse 

heavy;  it  will  show  the  number  of  new  patients 
and  ill   patients,  and   how  many  bed-baths  and 


TUBERCULOSIS  DIVISION 

DAILY  REPORT  TO  THE  HEALTH  DEPARTMENT  OF  BALTIMORE 
.                     i» 

ADDRESS 

WORK  DONE 

Visi  U  of  cooperation 

Visit*  to  arrange  for 
Vi*iU  to  inspect  after 

Fumiirntion                              NUM, 

Fumigation                                District  No. 

Nurse's  Daily  Report  Sheet,  seven  by  nine  inches 

dressings  were  given;  how  much  time  was  spent 
in  calling  on  doctors,  dispensaries,  social  workers, 
and  so  forth,  and  arranging  houses  for  fumigation. 


Nurse 
Distri 

DAY   SHEET 
TUBERCULOSIS  DIVISION. 

BALTIMORE  HEALTH  DEPARTMENT. 

ct  No  

DATB 

I" 

a 

1 

i5 

! 

i 

Sent  to  Dispensaries 

Sent  to  Bayview 

22 

ij 

IE 

li 

s'l 

c" 

1 

Sent  to  Jewish  Home 

I 

Visits  to  Patients 

1  Visits 
Before  Fumigation 

§ 
! 

f! 

1 
1 

Referred  for 
Relief 

jl 

Day  Sheet,  used  for  summarizing  the  day's  work.     From 
this  sheet  the  weekly  and  monthly  reports 

are  made  out  57 


58  The  Tuberculosis  Nurse 

In  short,  a  record  of  this  kind  shows  the  day's 
work  at  a  glance,  and  is  the  only  way  in  which  it 
can  be  satisfactorily  accounted  for,  and  if  necessary 
verified. 

True,  this  information  may  be  obtained  by 
going  over  the  charts  one  by  one,  and  verifying 
the  records  made  upon  them.  But  this  is  a  clumsy 
and  laborious  way  of  doing  it.  If  a  nurse  has 
two  hundred  charts  in  her  box,  and  pays  fifteen 
visits  a  day,  it  would  be  necessary  to  search 
through  the  whole  boxful  of  charts  in  order  to  find 
the  fifteen  cases  visited.  A  day  sheet  therefore,  is 
not  only  a  simple  and  practical  way  of  recording  a 
day's  work,  but  it  is  a  protection  both  to  the  nurse 
and  the  work  itself. 

Weekly  and  Monthly  Reports.  From  her  daily 
report  sheet,  the  nurse  should  make  up  a  weekly 
or  monthly  report,  to  be  turned  in  at  specified 
intervals.  This  weekly  or  monthly  balance  sheet 
should  be  presented  to  the  superintendent,  or  to 
the  officers  of  the  association  to  whom  the  nurse  is 
responsible.  Herewith  is  given  a  sample  of  the 
monthly  report  cards  used  in  Baltimore,  but  again 
attention  is  called  to  the  fact  that  these  are  not  the 
last  word  in  desirability.  In  using  them  as  models, 
they  would  of  course  be  altered  to  meet  local 
needs  or  conditions,  and  enlarged  or  changed  to 


Examination  of  Charts  59 

suit  other  requirements.  These  monthly  reports 
should  be  carefully  filed  away ;  they  are  needed  for 
the  construction  of  the  annual  report,  and  it  may 
be  necessary  to  refer  to  them  on  other  occasions. 


MONTHLY  REPORT 

OF  THE 

TUBERCULOSIS    DIVISION 
HEALTH    DEPARTMENT 

MONTH  OF _f9 — 


NUKSE DISTRICT  No- 


Sent  to  Jewish  Home  for 
New  Patients.  Consumptives. 


Patients  under  Supervision. 


Died  Cases  Registered. 


Discharged VisitS  toPatientS 

Balance.  BefOTe  Fumi*atlon' 


Sent  to  Dispensaries.  tet 


"  Eudowood 


"Bay  View 

41  State  Sanatorium _j  Agencies-Relief... 


'     of  Co-operation. 
Referred  to  Charitable 


Diet 


Card,  four  by  six  inches,  used  for  summarizing  the  weekly 
and  monthly  reports 

Examination  of  Charts.  One  of  the  duties  of 
the  superintendent  is  to  examine  the  patients' 
charts  from  time  to  time,  to  see  how  well  the 
nurses  do  the  clerical  work,  which  is  quite  as  im- 
portant as  the  visiting  itself.  By  carefully  exam- 
ining the  charts,  the  superintendent  is  able  to  call 
the  nurse's  attention  to  any  lapses  in  them— 
incomplete  histories,  long  intervals  between  visits, 


60  The  Tuberculosis  Nurse 

and  so  forth.  If,  for  any  reason,  the  nurse  allows 
considerable  time  to  elapse  between  her  visits  to  a 
patient,  the  reasons  for  this  should  be  fully  noted 
on  his  chart.  For  example:  some  one  wants  to 
know  when  Mrs.  Jones  was  last  visited.  On 
looking  at  the  chart,  we  find  the  last  visit  was  made 
on  June  first — and  it  is  now  August  first.  A  two- 
months'  gap  between  visits  looks  like  careless  and 
inattentive  work.  The  nurse,  being  questioned, 
however,  is  able  to  give  a  satisfactory  explanation 
—Mrs.  Jones  had  gone  to  pick  berries,  leaving  the 
city  the  first  of  June,  and  not  due  to  return  till  the 
first  of  September.  This  important  fact,  however, 
should  have  been  noted  on  the  chart,  since  it  is 
almost  as  careless  not  to  have  made  this  entry,  as 
it  would  have  been  to  neglect  the  patient  for  so 
long  a  time.  If  a  chart  is  to  have  any  value,  it 
should  tell  its  own  story,  briefly  and  clearly. 

These  charts,  therefore,  should  be  examined 
every  two  or  three  weeks.  It  is  the  duty  of  the  sup- 
erintendent to  go  over  these  records,  just  as  it  is  her 
duty  to  make  rounds  from  time  to  time  among  the 
patients,  and  visit  them  in  their  homes.  This  is 
done  by  the  superintendent,  not  in  a  spirit  of  dis- 
trust or  suspicion,  but  because  she  is  the  person  re- 
sponsible for  the  work,  and  it  is  her  duty  to  oversee 
it,  and  bring  it  to  its  highest  degree  of  efficiency. 


CHAPTER  VI 

Finding  Patients  and  Building  up  the  Visiting  List — Increasing 
the  Visiting  List — Social  Workers — Dispensaries — Patients' 
Family  and  Friends — Nurses'  Cases — Physicians. 

Finding  Patients  and  Building  up  the  Visiting 
List.  The  first  thing  for  a  nurse  to  do  when  she 
begins  her  work  in  a  new  community  is  to  find  the 
patients  she  is  to  instruct  and  care  for.  And  the 
question  naturally  arises ;  how  are  these  patients  to 
be  discovered? 

The  campaign  of  propaganda  concerning  the 
need  of  tuberculosis  work  has  aroused  the  interest 
of  people  of  all  classes.  The  funds  to  support  the 
nurse  are  evidence  of  this.  But  the  people  who 
pay  the  bills  are  not  those  who  can  produce  the 
patients.  To  get  in  touch  with  the  patients,  it  is 
necessary  to  approach  people  of  another  class, 
those  whose  work  brings  them  in  contact  with  the 
very  poor.  For,  as  a  rule,  in  beginning  tuberculosis 
work,  it  is  only  patients  of  the  poorest  class  who 
find  their  way  to  the  nurse's  visiting  list.  Later, 
as  the  work  becomes  more  firmly  established,  and 
better  known  and  understood,  her  visiting  list  will 

61 


62  The  Tuberculosis  Nurse 

include  not  only  the  poor,  but  those  in  well-to-do 
and  comfortable  circumstances. 

The  Board  of  Managers  of  the  new  association 
may  interest  themselves  in  finding  the  patients, 
but  in  the  end  it  is  the  nurse  herself  upon  whom 
this  responsibility  rests.  Upon  her  initiative  and 
ability  depends  the  success  of  the  work.  Her  first 
step,  therefore,  should  be  to  call  upon  all  those 
who  can  in  any  way  be  of  service,  and  who  can 
direct  her  to  the  patients  she  is  anxious  to  reach. 
She  should  call  upon  the  physicians  of  the  com- 
munity, the  dispensaries  and  hospitals  (if  there 
are  any),  social  workers,  such  as  the  agents  of 
charitable  associations;  priests,  clergymen,  and 
all  those  who  come  into  contact  with  the  suffering 
and  the  destitute.  Her  visits  should  be  made  in 
person,  since  a  personal  interview  makes  a  stronger 
appeal  to  the  memory  of  the  busy  man  than  the 
most  convincing  letter  or  the  most  eloquent  re- 
port. This  involves  one  great  reason  why  the 
nurse  should  be  thoroughly  equipped  in  character 
and  training;  the  colourless,  uneducated,  uncon- 
vincing woman  carries  with  her  no  conviction,  and 
inspires  no  confidence  either  in  herself,  or  in  what 
she  proposes  to  do.  A  physician  may  well  hesitate 
about  turning  over  his  patients  to  a  woman  who  is 
unable  to  put  her  case  before  him. 


Increasing  the  Visiting  List         63 

It  may  be  that  considerable  time  will  thus  have 
to  be  spent  in  calling  upon  all  those  likely  to  know 
of  tuberculous  patients,  and  therefore  able  to  fur- 
nish the  nurse  with  the  necessary  names  and 
addresses.  That  the  response  is  not  great  should 
cause  no  discouragement.  As  we  have  said  else- 
where, the  tuberculosis  death-rate,  multiplied  by 
five,  will  give  a  conservative  estimate  of  the 
number  of  tuberculous  individuals  in  a  commun- 
ity. It  is  the  nurse's  duty  to  unearth  them.  They 
exist — she  must  find  them,  and  the  greater  the 
obstacles,  the  greater  the  incentive  to  overcome 
them.  The  total  result  of  a  two  or  three  weeks' 
campaign  may  be  a  mere  handful  of  cases  reluc- 
tantly handed  over  by  a  few  physicians,  and  a  few 
undiagnosed  suspects,  reported  by  an  earnest 
priest.  In  this  way  the  visiting  list  is  begun. 

Increasing  the  Visiting  List.  To  increase  the 
visiting  list — that  is,  to  bring  under  her  care  an 
increasingly  larger  proportion  of  the  total  number 
of  tuberculous  patients,  even  though  the  list  be- 
comes so  large  and  unwieldy  that  she  cannot 
manage  it,  should  be  the  ambition  of  every  tu- 
berculosis nurse.  At  present,  in  every  city  in  the 
country,  there  is  so  much  undiscovered  and  un- 
reported  tuberculosis,  that  the  failure  of  the  nurse 
to  increase  the  visiting  list  is  an  indication  of  poor 


64  The  Tuberculosis  Nurse 

work,  not  an  indication  that  a  full  round-up  has 
been  made  of  all  those  suffering  from  this  disease. 
This  is  especially  true  in  a  new  community ;  a  small 
or  stationary  visiting  list  is  a  sure  sign,  not  neces- 
sarily of  lazy  or  unconscientious  work,  but  at  least 
that  the  undertaking  is  being  managed  by  someone 
who  does  not  know  how. 

To  illustrate  this:  A  nurse  is  sent  to  a  certain 
house,  to  see  a  specified  patient.  She  does  her 
work  well — gives  him  a  bed-bath,  shows  the  family 
what  to  do,  and  makes  considerable  impression 
along  lines  of  general  hygiene.  As  far  as  it  goes, 
her  work  is  satisfactory  and  good.  Another  nurse, 
however,  sent  into  this  same  house,  would  not  only 
do  all  these  things  equally  well,  but,  in  addition, 
she  would  discover  that  the  patient's  wife  was 
coughing  and  probably  infected,  while  his  old 
mother,  retired  in  the  chimney-corner,  was  in  even 
worse  plight  than  the  patient  himself.  These 
suspects,  therefore,  she  sends  to  the  dispensary, 
where  her  suspicions  are  confirmed  by  the  doctor's 
findings.  Thus,  if  a  community  possesses  a  nurse 
of  the  first  type,  it  may  rejoice  to  find  the  amount 
of  tuberculosis  so  small.  If,  on  the  other  hand,  it 
has  a  woman  of  the  second  type,  it  will  become 
alarmed  and  anxious  at  the  increasing  number  of 
patients  who  need  care  and  control. 


Increasing  the  Visiting  List         65 

Nothing  should  diminish  the  enthusiasm  for 
gaining  new  patients.  The  mere  fact  that  a  nurse 
has  more  than  she  can  manage  should  never  deter 
her  from  continually  trying  to  find  more.  More 
patients,  more  patients,  and  even  then,  more 
patients,  should  be  her  constant  aim — and  then 
the  chances  are  that  she  has  not  found  all  that 
exist.  In  Baltimore,  when  pioneer  work  was  begun 
under  the  Visiting  Nurse  Association,  that  or- 
ganization had  a  visiting  list  of  some  1 700  consump- 
tive patients,  divided  among  five  nurses.  As  five 
nurses  represented  the  largest  number  the  Asso- 
ciation could  support,  and  as  1700  patients  was 
only  about  one-fourth  of  those  who  needed  care 
and  attention,  some  other  method  of  caring  for  the 
latter  had  to  be  devised.  It  was  at  this  critical 
moment  that  the  Health  Department  was  per- 
suaded to  assume  the  tuberculosis  work  of  the 
private  association,  and  to  incorporate  it  as  part 
of  the  city  machinery.  If  the  need  for  this  trans- 
fer had  never  been  proved,  it  is  hardly  possible 
that  the  change  would  have  been  made.  If  the 
first  nurses  had  confined  their  visits  to  the  patients 
they  could  reasonably  manage,  and  had  refused 
to  accept  others,  it  would  have  been  impossible  to 
prove  how  great  the  number  of  infectious  patients 
was,  and  how  inadequate  the  care  given  them  by 


66  The  Tuberculosis  Nurse 

the  five  struggling  nurses  of  the  private  association. 
Therefore,  each  community  which  undertakes  tu- 
berculosis work  should  endeavour  to  unearth  all 
the  cases  that  exist,  if  for  no  other  reason  than  to 
show  the  size  of  the  problem,  and  the  necessity  of 
adequate  measures  for  handling  it.  New  patients, 
positive  and  suspicious,  should  be  sought  for  from 
every  possible  source.  This  is  better  policy  than 
to  confine  the  work  to  the  conscientious  care  of  a 
handful  of  manageable  cases. 

Social  Workers.  The  agents  of  the  Charity 
Organization  Society,  or  similar  associations,  con- 
tinually come  across  cases  of  tuberculosis.  The 
new  nurse  should  canvass  all  these  agencies,  and 
ask  that  all  cases  of  this  kind  be  referred  to  her.  If 
a  case  is  not  positively  diagnosed,  -that  should  be 
no  drawback  to  reporting  it;  while  the  agents  of 
these  associations  are  laymen  and  therefore  not  able 
to  make  diagnoses,  laymen,  nevertheless,  are  able 
to  make  very  shrewd  guesses.  It  is  the  nurse's 
duty  to  take  charge  of  these  doubtful  cases,  and 
get  them  examined  and  diagnosed  by  the  proper 
agencies.  The  mere  fact  that  a  patient  presents 
suggestive  symptoms  makes  it  all  the  more  urgent 
that  he  be  examined  as  soon  as  possible,  and  lack 
of  positive  diagnosis  should  be  no  reason  for  the 
agent  to  withhold,  or  for  the  nurse  to  refuse  to  take 


Dispensaries  67 

charge  of,  such  a  case.  To  visit  a  suspect  does  not 
necessarily  classify  him  as  a  consumptive,  while 
not  to  visit  him  might  be  to  deprive  him  of 
assistance  at  a  most  critical  time. 

In  finding  cases,  extensive  co-operation  should  be 
invited;  almost  every  one  whose  work  brings  him 
into  contact  with  numbers  of  people,  knows  one  or 
two  among  them  who  are  tuberculous.  Thus 
settlement  workers,  school  teachers,  school  attend- 
ance officers,  juvenile  court  officers,  clergymen, 
Salvation  Army  workers,  and  so  forth,  are  all 
people  whose  aid  and  interest  should  be  solicited. 
It  makes  no  difference  whether  or  not  the  case  is 
positively  diagnosed — any  sick  person,  with  the 
symptoms  of  a  consumptive,  is  a  person  whose 
case  should  be  looked  into.  It  is  the  nurse's  busi- 
ness to  obtain  the  diagnosis. 

Dispensaries.  If  there  is  a  hospital  or  dispen- 
sary (not  necessarily  a  tuberculosis  dispensary), 
the  nurse  should  visit  these  institutions  and  ask  to 
have  all  positive  and  suspicious  cases  referred  to 
her.  Since  the  patients  who  come  to  these  places 
are  usually  those  of  the  poorer  classes,  the  doctors 
will  not  be  likely  to  object  to  giving  their  names  to 
the  nurse.  Indeed,  they  may  be  glad  to  accept 
the  assistance  she  offers.  One  visit  to  these  in- 
stitutions, however,  is  not  enough.  Every  week  or 


68  The  Tuberculosis  Nurse 

two  the  nurse  must  present  herself  and  renew  her 
request  for  patients — she  must  not  trust  to  the 
busy  physician  to  report  them  by  letter  or  tele- 
phone. Even  when  tuberculosis  work  is  conducted 
on  a  large  scale,  as  in  Baltimore,  it  is  always  part 
of  the  nurse's  duty  to  visit  these  institutions 
regularly,  to  remind  the  doctors  of  their  existence 
and  of  their  unquenchable  desire  for  more 
patients. 

Patients'  Families  and  Friends.  After  the  nurse 
is  well  established,  and  her  position  in  the  commun- 
ity recognized  and  assured,  she  will  find  that  a 
certain  number  of  new  cases  are  referred  to  her 
through  the  families  and  friends  of  those  already 
on  her  visiting  list.  This  is  a  high  tribute,  and 
should  be  valued  accordingly.  She  should  not 
rely  entirely  upon  this  voluntary  assistance,  how- 
ever, but  from  time  to  time  should  question  her 
patients,  and  find  out  whether  they  have  any 
friends  who  are  ill,  who  would  like  to  be  visited. 
Surprising  revelations  often  follow.  There  was 
in  Baltimore  one  old  coloured  woman  who  took 
special  pride  in  discovering  patients,  and  who 
made  an  indefatigable  agent  in  hunting  up  cases 
in  the  neighbourhood.  The  accuracy  of  her  diag- 
nosis was  wonderful — her  son  had  died  of  tuber- 
culosis, so  she  knew  all  the  symptoms,  and  she  did 


Nurse's  Cases  69 

not  refer  us  to  a  single  case,  which,  upon  examina- 
tion, failed  to  be  tuberculous.  We  must  remember 
that  while  in  its  early  stages  tuberculosis  is  difficult 
to  detect,  when  it  is  so  advanced  that  a  layman  can 
recognize  it,  in  nine  times  out  of  ten  he  is  right. 
And  as  these  advanced  cases  are  the  chief  dis- 
tributors of  the  disease,  the  alert  nurse  should  be 
keen  to  learn  of  these  patients  through  any  source 
that  presents  itself.  Of  course  many  calls  from 
such  sources  send  one  on  mere  wild-goose  chases, 
but  it  is  better  to  go  on  a  dozen  fruitless  errands, 
than  to  overlook  one  real  case  of  tuberculosis. 

Nurse's  Cases.  A  large  proportion  of  her  cases 
will  be  unearthed  by  the  nurse  herself.  In  Balti- 
more, the  nurses  themselves  discover  nearly  thirty- 
three  per  cent,  of  the  cases  under  supervision. 
Thus,  on  being  sent  to  see  a  certain  patient,  before 
her  visit  is  over  the  nurse  may  discover  one  or  two 
others  of  the  family  whose  condition  is  such  as  to 
call  for  immediate  examination.  The  nurse  should 
look  with  suspicion  upon  every  member  of  a 
household  which  has  been  exposed  to  tuberculosis. 
The  prolonged  and  intimate  contact  which  is 
necessary  for  the  transmission  of  this  disease  has 
unfortunately,  in  most  families,  existed  for  months 
before  her  arrival.  The  nurse  should  be  particu- 
larly keen  in  questioning  the  parents  of  tubercu- 


70  The  Tuberculosis  Nurse 

lous  children   since  it  is  from  the  parents  that 
most  children  contract  this  disease. 

Physicians.  In  considering  the  various  sources 
from  which  patients  are  recruited,  we  have  pur- 
posely left  until  the  last  that  which  most  people 
would  have  deemed  the  first  and  most  important 
source  of  all,  namely,  the  physicians  of  a  commun- 
ity. While  the  medical  profession  has  blazed  the 
way,  and  has  indicated  the  paths  along  which 
the  work  must  be  carried  on,  it  is  unfortunately 
only  the  greater  men  in  the  profession  who  have 
done  this.  The  others,  through  ignorance,  through 
indifference,  or  through  that  spirit  which  according 
to  Dr.  Cabot  makes  medicine  "the  greatest  pro- 
fession, the  meanest  of  trades,"  have  succeeded 
in  placing  effective  if  temporary  barriers  in  the 
path  of  the  anti-tuberculosis  worker.  The  rigid 
adherence  to  the  old  Hippocratic  oath,  by  which 
the  physician  was  sworn  to  keep  inviolate  the 
confidence  of  his  patient,  and  to  place  foremost  the 
welfare  of  the  individual,  has  for  the  most  part 
been  very  nobly  lived  up  to.  This  oath,  however, 
antedates  our  knowledge  concerning  infectious  and 
communicable  disease.  With  the  knowledge  as  to 
the  nature  of  transmissible  diseases,  there  has 
come  a  change  in  medical  ethics,  a  change  mani- 
fested by  laws  in  which  the  welfare  of  the  com- 


Physicians  71 

munity  is  placed  above  that  of  the  individual.  We 
see  this  reflected  in  the  regulations  governing 
diphtheria,  smallpox,  scarlet  fever,  and  so  forth— 
diseases  which  are  distinctly  the  concern  of  the 
community,  as  well  as  of  the  patient  himself.  But 
with  tuberculosis,  which  has  but  recently  become 
recognized  as  a  communicable  disease,  we  find 
a  halting  reluctance  to  consider  anything  but  the 
rights  of  the  individual.  This  feeling  is  particu- 
larly strong  among  physicians  of  an  older  genera- 
tion, hold-overs  from  a  passing  regime.  To  such 
as  these  the  nurse  is  nothing  less  than  an  imperti- 
nence. Even  if  physicians  of  this  sort  are  unable 
to  see  their  patients  oftener  than  once  or  twice  a 
year,  or  know  them  to  be  in  need  of  supplies 
which  the  nurse  will  gladly  furnish,  they  refuse 
to  call  upon  her,  and  consider  her  advent  as 
intolerable. 

Again,  there  are  physicians  who  do  not  object 
to  the  nurse  on  this  score,  but  who  resent  her  as  a 
subtle  menace  to  their  practice.  They  feel  that  if 
a  layman  is  able  to  preach  rest,  fresh  air,  and  food, 
and  distribute  prophylactic  supplies,  that  the 
ground  will  be  cut  out  from  under  them,  and  that 
they  will  lose  a  chronic  and  fairly  lucrative  class  of 
patients.  As  a  matter  of  fact,  the  physician  who 
preaches  this  simple  doctrine  has  nothing  to  fear 


72  The  Tuberculosis  Nurse 

from  the  tuberculosis  nurse — if  her  words  echo  his 
they  only  add  force. 

There  are  other  physicians,  however,  who  have 
received  an  inferior  medical  education;  they  are 
neither  sure  of  themselves,  nor  able  to  diagnose 
tuberculosis  until  it  is  in  an  advanced  state. 
These  object  to  the  nurse  on  the  ground,  implied 
rather  than  expressed,  that  she  is  supervising  and 
criticizing  their  work,  and  this  self-consciousness 
often  takes  the  form  of  a  violent  antagonism.  It  is 
always  the  badly  trained  physician  who  fears  the 
well-trained  nurse. 

Furthermore,  there  are  certain  practitioners  who 
frankly  exploit  their  patients.  They  may  be 
competent  enough  but  they  are  in  medicine  to 
make  a  living,  and  are  often  brutally  unethical  as 
to  how  this  is  done.  If  through  self-interest  it 
seem  best  to  them  to  withhold  from  the  patient  the 
nature  of  his  disease,  they  do  not  hesitate  to  do  so, 
regardless  of  the  danger  to  which  others  may  be 
exposed.  By  a  strange  paradox,  the  same  profes- 
sion which  gives  us  the  noblest,  the  most  unselfish 
workers  in  the  interests  of  public  health,  also  gives 
us  its  most  implacable  enemies. 

However,  the  new  nurse  must  call  upon  all  the 
physicians  of  the  community,  and  endeavour  to 
obtain  their  assistance  and  support.  But,  for  the 


Physicians  73 

reasons  mentioned,  she  must  not  be  discouraged 
if  she  is  not  always  cordially  received  by  them. 
There  will  always  be  among  them  many  who  are 
enlightened  and  progressive,  and  who  will  assist 
generously  in  the  an ti- tuberculosis  campaign.  If 
a  community  can  boast  of  only  one  or  two  such 
men,  even,  success  is  assured.  And  later  on,  as  the 
nurse  progresses  quietly  in  her  work,  she  will  come 
into  contact  with  other  doctors,  who  promise  her 
aid,  but  ignore  their  promises  because  they  think 
she  is  trying  to  steal  away  their  patients.  As  it 
gradually  dawns  on  them  that  this  is  not  the  case, 
their  opposition  will  wear  off.  To  conquer  this 
prejudice  as  soon  as  possible  is  part  of  the  nurse's 
work. 

Furthermore,  the  community  itself  should  not 
be  daunted  if  the  physicians  as  a  body  do  not 
endorse  the  prospect  of  a  tuberculosis  nurse.  This 
prejudice  against  public  health  nursing  is  the  com- 
mon experience  in  all  cities  where  visiting  work  has 
been  established,  but  it  gradually  wears  off  as  the 
nurse  is  able  to  demonstrate  her  value.  Little  by 
little  the  doctors  are  won  over,  as  they  begin  to 
realize  that  she  is  not  a  rival  but  an  assistant.  In 
Baltimore,  our  experience  has  been  that  those  phy- 
sicians who  were  at  first  our  worst  opponents  have 
now  become  our  staunchest  and  warmest  friends. 


CHAPTER  VII 

The  General  Practitioner  and  the  Public  Health — Responsibility 
of  the  Private  Practitioner  in  Tuberculosis — Impossibility  of 
Fulfilling  this  Obligation — Failure  because  of  the  Nature  of 
Tuberculosis — Failure  through  the  Personal  Equation. 

The  General  Practitioner  and  the  Public  Health. 

Roughly  speaking,  we  may  say  that  the  medical 
profession  is  divided  into  three  or  four  branches — 
private  practice,  hospital  or  laboratory  work,  and 
public  health  service.  A  man  who  takes  up  one  of 
these  branches  is  not  necessarily  interested  in  or 
equipped  for  another.  While  all  physicians  are 
supposed  to  have  approximately  the  same  medical 
education,  and  therefore  to  be  interested  in  those 
measures  which  tend  to  raise  and  improve  the 
standard  of  public  health,  it  is  only  those  who  are 
most  keenly  interested  in  this  work  who  have  made 
it  a  special  study.  For  it  must  be  remembered 
that  public  health  work  is  as  much  a  specialty  and 
calls  for  as  much  training  and  ability  along  certain 
lines  as  laboratory  work,  or  the  administration  of 
an  institution.  This  being  so,  a  man  who  goes  in 

74 


The  Private  Practitioner  75 

for  it  does  so  because  he  is  more  interested  in  it 
than  in  private  practice,  or  in  research  work.  And 
the  converse  of  this  is  also  true.  The  selection  of 
one  field  rather  than  another  is  a  matter  of  indi- 
vidual taste  or  inclination.  Yet  curiously  enough, 
the  State  does  not  take  note  of  this  fact.  It 
places  certain  obligations  upon  all  members  of  the 
medical  profession,  and  expects  them  all  to  live 
up  to  the  responsibilities  thus  arbitrarily  imposed. 
Responsibility  of  the  Private  Practitioner  in  Tu- 
berculosis. In  the  pursuit  of  his  calling,  the  private 
practitioner  comes  into  contact  with  certain  dis- 
eases which  by  their  nature  are  a  matter  of  public 
as  well  as  private  concern.  In  so  far,  therefore,  he 
is  expected  to  interest  himself  in  the  general  welfare 
of  the  community,  but  there  is  no  way  of  compell- 
ing him  to  do  this.  The  State  grants  him  a  licence 
to  practice  medicine,  and  in  exchange  for  this 
licence  or  permission,  he  is  expected  to  serve  the 
State  more  or  less  gratuitously.  At  best,  it  is 
volunteer  service,  and  therefore  intermittent  and 
unsatisfactory.  That  the  State  expects  this  ser- 
vice is  shown  by  laws  referring  to  transmissible 
diseases,  the  notification  of  births  and  deaths,  and 
other  matters  which  in  one  sense  belong  to  his 
private  business,  but  which  in  another  sense  are 
part  of  his  public  responsibility. 


76  The  Tuberculosis  Nurse 

Physicians  who  have  no  taste  for  research  work 
are  not  forced  to  undertake  it,  nor  are  they  coerced 
into  any  other  line  of  service.  Yet  the  State 
obliges  those  who  are  least  inclined,  as  well  as  the 
others,  to  assume  a  graver  responsibility ;  care  of  the 
public  health.  It  takes  no  account  of  the  many 
reasons  which  may  prevent  their  doing  this,  or 
prevent  their  willingness  to  assume  any  part  of  this 
responsibility.  It  is  thrust  upon  them  just  the 
same,  but  the  expected  results  are  not  forthcoming. 
The  State,  therefore,  is  in  the  position  of  making 
an  unfair  demand  upon  the  private  practitioner, 
and  at  the  same  time  relying  upon  an  unfulfilled 
requirement  for  the  security  of  the  public  health. 
In  regard  to  tuberculosis,  there  are  certain  regula- 
tions which  all  physicians  are  supposed  to  comply 
with,  no  matter  how  little  interested  they  may  be 
in  public  welfare,  or  how  unwilling  to  consider  any 
other  than  their  personal  interests.  These  laws 
require,  first,  that  all  cases  of  tuberculosis  be 
registered  with  the  local  or  state  health  depart- 
ment, since  in  dealing  with  a  transmissible  disease 
it  is  necessary  to  learn  its  distribution  and  preva- 
lence. Second,  the  physician  in  charge  of  a 
tuberculous  patient  must  give  this  patient  full 
prophylactic  supplies,  and  teach  him  how  to  use 
and  dispose  of  them.  These  supplies  are  furnished 


The  Private  Practitioner  77 

free  of  charge  by  the  Health  Department,  so  that 
the  physician  is  under  no  expense  in  distributing 
them.  Third,  all  houses  vacated  by  a  consump- 
tive, either  through  death  or  removal,  must  be 
reported  to  the  Health  Department  for  fumiga- 
tion. If  these  regulations  could  have  been  thor- 
oughly complied  with,  they  would  doubtless  have 
insured  a  system  of  complete  and  satisfactory 
supervision  of  tuberculosis.  As  it  is,  most  of  our 
large  cities  have  found  it  necessary  to  place  special 
workers  in  the  field,  to  give  exactly  the  same  super- 
vision and  control  which  these  regulations  were 
designed  to  secure.  The  private  practitioner,  en- 
dowed with  special  education,  special  opportunity, 
and  special  authority,  has  not  used  these  endow- 
ments, or  else  has  used  them  to  so  slight  an  extent 
that  the  community  has  received  no  benefit. 

If  the  physicians  of  a  community  have  been  able 
to  diagnose  tuberculosis,  and  have  been  required 
by  law  to  report  it,  why  has  it  become  necessary 
to  establish  municipal  dispensaries  for  this  pur- 
pose? Can  the  dispensary  physician  make  a 
better  diagnosis?  Or  is  he  more  willing  to  fill  in  a 
blank  and  report  the  case? 

And  if  the  physicians,  required  by  law  to  in- 
struct and  keep  careful  watch  over  their  con- 
sumptive patients,  had  been  able  to  do  this,  why 


78  The  Tuberculosis  Nurse 

has  it  become  necessary  to  place  tuberculosis 
nurses  in  the  field,  designed  to  give  just  such 
service?  Is  the  special  nurse  better  fitted  to 
explain  the  nature  and  danger  of  the  disease?  Is 
she  a  more  efficient  distributor  of  prophylactic 
supplies?  To  all  these  questions  there  should  be 
but  one  answer — there  is,  or  should  be,  no  differ- 
ence between  the  two.  The  private  practitioner 
should  be  as  well  able  to  make  a  sure  diagnosis  as 
the  municipal  physician.  He  should  be  as  ready 
to  report  the  case.  The  private  practitioner  should 
be  as  capable  a  teacher,  as  careful  a  distributor  of 
supplies,  as  alive  to  the  danger  of  tuberculosis  as 
the  municipal  nurse.  The  only  difference  between 
these  two  groups  of  people  is  that  one  acts  and  the 
other  does  not — or  acts  in  such  intermittent  and 
irregular  manner  as  to  be  productive  of  no  results. 
And  it  is  because  of  this  lack  of  action  on  the  part 
of  the  physicians  in  private  practice,  their  failure 
to  recognize,  report,  teach,  and  continually  super- 
vise consumptive  patients,  that  our  cities  are 
placing  the  care  of  tuberculosis  under  municipal 
control.  The  care  of  tuberculosis  is  gradually 
being  withdrawn  from  the  man  in  private  practice, 
and  placed  in  the  hands  of  specialists,  who  devote 
their  entire  time  to  the  welfare  of  the  community. 
And  although  now  as  always  the  latter  solicit  the 


Private  Practitioner's  Failure        79 

support  of  the  private  physician,  if  he  withholds 
his  co-operation  they  can  do  without  him,  and 
reach  their  goal  through  other  means. 

Impossibility  of  Fulfilling  this  Obligation.  We 
may  ask  why  the  private  practitioner  is  being 
supplanted  by  municipal  control.  Undoubtedly 
he  once  held  the  key  of  the  tuberculosis  situation, 
as  he  holds  it  of  many  other  problems  involving 
the  public  health.  He  is  being  supplanted  for 
two  reasons:  because  of  the  peculiar  nature  of 
tuberculosis,  and  because  of  the  failure  of  the 
medical  profession  to  act  as  a  united  whole. 

Failure  because  of  the  Nature  of  Tuberculosis. 
Let  us  first  consider  the  nature  of  the  disease. 
Tuberculosis  is  a  prolonged,  chronic  disease,  which 
may  be  drawn  out  over  a  period  of  months  or 
years.  The  patient  has  many  ups  and  downs, 
being  sometimes  so  ill  that  he  places  himself 
under  the  care  of  a  physician,  sometimes  so  much 
better  that  he  does  not  see  a  doctor  for  months. 
We  have  known  patients  who  have  not  been  to  a 
physician  for  years,  yet  during  that  time  they 
were  infectious  cases,  as  proved  by  sputum  ex- 
amination. During  a  hiatus  of  this  kind,  how  can 
we  possibly  hold  the  doctor  responsible  for  the 
tuberculous  patient?  How  can  we  hold  him  res- 
ponsible for  the  conduct,  training,  and  surroundings 


8o  The  Tuberculosis  Nurse 

of  a  case  he  never  sees?  Undoubtedly  a  very  large 
number  of  patients  pass  completely  from  under  the 
observation  of  their  physicians,  and  are  utterly  lost 
to  them.  With  the  best  intentions  in  the  world, 
the  private  practitioner  cannot  follow  and  supervise 
a  disease  of  this  character,  not  acute,  but  chronic 
and  ambulatory  in  nature.  If  he  attempted  this, 
it  would  leave  him  little  time  for  anything  else. 

Nor  can  we  assume  that  the  patient  who  closes 
Ms  account  with  one  doctor  necessarily  places 
himself  in  the  hands  of  another.  He  frequently 
drifts  along  without  any  medical  advice  whatso- 
ever, and  only  seeks  it  again  when  his  symptoms 
become  alarming.  These  facts  alone,  exclusive  of 
all  other  considerations,  show  the  necessity  for 
centralized  control  of  these  ambulatory  patients. 

Tuberculosis  is  largely  a  disease  of  the  poor,  as 
we  have  remarked  before.  A  poor  consumptive 
must  consider  the  spending  of  every  dollar,  and 
the  doctor's  fee  is  a  matter  of  grave  importance. 
For  this  reason,  the  patient  will  pay  just  as  few 
visits  to  the  physician  as  he  possibly  can.  A 
doctor  who  sees  a  case  only  once  or  twice  may  well 
hesitate  to  pronounce  it  tuberculosis,  and  may 
wish  to  keep  the  patient  under  observation  for  a 
time,  but  /the  poverty  of  the  patient  prevents  this. 

Again,  patients  of  the  poorer  classes  continually 


Private  Practitioner's  Failure        81 

change  their  doctors.  Unlike  people  in  more 
fortunate  circumstances,  they  have  no  one  phy- 
sician to  whom  they  always  turn  when  in  trouble. 
To  such  as  these,  the  "family  doctor"  is  unknown. 
Their  fickle  interest  is  attracted  by  the  newest 
shingle,  and  they  pay  a  visit  or  two  to  its  owner 
and  they  depart.  We  knew  one  patient  who  visited 
five  different  doctors  within  the  week.  Small 
wonder  that  the  doctor  forgets  these  patients — 
mere  transients- — and  that,  even  if  he  has  time  to 
diagnose  them,  he  does  not  consider  himself  their 
physician,  or  responsible  for  them  in  any  way.  It 
is  for  just  such  cases,  however — those  patients  who 
come  into  fleeting  and  haphazard  relation  with 
their  physician,  that  municipal  control  is  required. 
It  is  no  reflection  upon  the  private  practitioner 
that  he  has  failed  to  make  headway  against  tu- 
berculosis. It  simply  proves  that  people  with  this 
disease  must  be  watched  and  cared  for  by  those 
who  are  able  to  devote  their  entire  time  to  it. 

So  much  for  the  disease  itself,  and  for  the 
sociological  and  psychological  conditions  which 
complicate  it,  and  make  it  a  matter  which  cannot 
be  ^handled  successfully  by  the  man  in  private 
practice.  For  no  matter  how  conscientious  he  may 
be,  or  how  willing  to  assume  the  full  responsibility 
imposed  by  the  State,  he  cannot  do  this  when  the 


82  The  Tuberculosis  Nurse 

patients  refuse  him  the  opportunity.  He  cannot 
follow  them  up  at  the  expense  of  his  private 
obligations.  While  the  State  expects  service  from 
those  whom  it  licenses  to  practise,  it  does  not 
expect  the  impossible. 

Failure  through  the  Personal  Equation.  We 
must  now  consider  the  second  reason  for  removing 
tuberculosis  from  private  into  public  control. 
For  while  the  nature  of  the  disease  itself  explains 
in  large  measure  why  it  cannot  be  dealt  with  by  the 
private  practitioner,  that  is  not  the  entire  explana- 
tion. And  here  we  must  put  the  blame  where  it 
belongs — at  the  door  of  the  physician  himself. 

When  we  think  of  the  medical  profession,  we 
unconsciously  think  of  its  finest  members — not 
only  of  the  leaders  in  thought  and  achievement, 
but  the  numbers  of  highly  educated,  advanced, 
efficient,  and  conscientious  men  who  form  so  large 
a  part  of  it.  In  thinking  of  these,  however,  we  are 
apt  to  overlook  men  of  another  sort,  who  are  less 
well  equipped,  or  who  are  imbued  with  commercial- 
ism, yet  who  are  none  the  less  members  of  this 
great  profession.  Yet  even  the  least  of  these  is 
armed,  and  has  the  sanction  of  the  State  in  bearing 
these  arms,  which  may  be  used  either  against  a 
common  enemy,  or  in  a  guerilla  warfare  in  behalf 
of  his  own  interests.  The  wide  diversity  among  its 


Failure  through  Personal  Equation    83 

individual  members  is  the  reason  why  the  medical 
profession  has  been  unable  to  act  as  a  united  whole 
in  the  warfare  against  tuberculosis. 

In  the  first  place,  all  physicians,  no  matter  how 
well  they  may  be  trained,  are  not  necessarily  good 
teachers.  No  matter  how  keenly  aware  of  the 
danger  of  tuberculosis,  they  are  often  unable  to 
impress  it  upon  their  patients.  Again,  the  busy 
physician  has  usually  too  little  time  to  be  a  careful 
teacher.  When  conscious  of  a  crowded  waiting- 
room,  or  of  the  urgency  of  his  next  call,  he  is 
unable  to  give  any  but  the  most  superficial  and 
hurried  instructions  about  the  nature  of  tubercu- 
losis, or  the  use  of  the  prophylactic  supplies.  He 
does  not  realize  that  that  which  is  obvious  to  him 
is  frequently  unintelligible  to  those  less  enlight- 
ened. We  have  often  found  patients  possessing 
bundles  of  prophylactic  supplies,  given  conscien- 
tiously enough,  but  without  sufficient  instruction 
to  enable  them  to  fold  the  fillers  or  to  dispose  of 
them  afterwards.  We  recall  one  such  case,  where 
the  doctor  had  given  his  patient  a  package  of 
supplies,  but  had  hurried  off  without  opening  the 
bundle  or  explaining  its  contents.  A  week  later,  we 
found  the  package  still  unopened.  The  patient, 
however,  had  torn  a  small  hole  in  the  wrapper, 
through  which  opening  he  had  seen  enough  to 


84  The  Tuberculosis  Nurse 

convince  himself  that  the  strange  objects  within 
were  no  concern  of  his.  We  do  not  mean  to  say 
that  no  physicians  are  good  teachers,  but  we  do 
say  that  even  where  they  are,  and  are  moreover 
highly  conscientious  men,  that  they  frequently 
give  inadequate  instruction  to  the  patients  under 
their  charge,  because  they  are  too  busy. 

There  is  another  class  of  practitioners,  who,  while 
willing  enough,  are  nevertheless  unable  to  con- 
tribute much  towards  the  anti-tuberculosis  cam- 
paign. These  are  the  men  whose  education  is 
limited,  who  are  unable  to  recognize  tuberculosis 
until  it  is  advanced,  and  even  then  hesitate  to 
commit  themselves.  The  patient  under  these 
circumstances  has  ample  opportunity  to  infect 
others,  to  say  nothing  of  losing  his  own  life  into 
the  bargain.  No  amount  of  conscientiousness,  of 
integrity,  and  of  honest  intention  can  compensate 
for  lack  of  skill.  Indeed,  many  men  of  this  sort 
come  perilously  near  the  border-line  of  quackery. 
Yet  the  State  has  granted  them  a  licence,  though 
thereby  it  entrusts  them  with  obligations  which 
they  cannot  fulfil. 

We  have  spoken  before  of  the  unethical  practi- 
tioner, who,  while  competent  enough,  feels  himself 
under  no  obligation  to  protect  the  community 
from  an  infectious  disease.  There  is  sometimes 


Failure  through  Personal  Equation    85 

a  reason  for  this  indifference,  this  failure  to  tell  the 
patient  he  has  tuberculosis,  and  to  inform  those 
who  surround  him  of  their  danger.  This  reason  is 
because  many  a  patient  is  afraid  to  know  the  truth 
about  his  condition.  If  the  physician  tells  him  he 
has  tuberculosis,  he  at  once  changes  his  doctor  and 
seeks  another  who  will  give  a  more  comforting 
diagnosis.  Thus,  the  struggling  physician,  to  whom 
this  may  mean  the  loss  of  livelihood  and  prestige, 
is  forced  to  a  decision  between  self-interest  and  the 
interest  of  a  community  which  he  learns  to  despise, 
because  it  has  forced  him  to  dishonesty.  We  grow 
cynical  about  the  welfare  of  those  who  force  us  to 
trim  our  ideals. 

We  have  tried  thus  briefly  to  review  the  main 
reasons  why  tuberculosis  is  emphatically  a  disease 
which  should  be  removed  from  private  practice 
and  placed  under  municipal  control.  On  the  one 
hand,  this  is  necessary  because  of  the  nature  of  the 
disease,  since  ambulatory  patients  cannot  be  fol- 
lowed except  by  those  able  to  devote  their  whole 
time  to  it.  On  the  other  hand,  it  is  necessary 
because  of  the  wide  diversity  within  the  ranks  of 
the  medical  profession.  The  greater  number  of 
private  practitioners  are  either  too  busy,  too  in- 
tent on  earning  a  living,  too  indifferent,  or  too 
poorly  educated  to  assume  effective  supervision 


86  The  Tuberculosis  Nurse 

of  an  infectious  disease  which  requires  masterful 
handling.  And  since  they  themselves  have  not 
been  able  to  deal  with  this  great  issue,  they  should 
not  object  to  placing  it  in  the  hands  of  those 
qualified  to  do  so.  The  greatest  contribution  that 
the  private  physician  can  make  to  the  anti-tu- 
berculosis campaign,  is  to  do  what  he  can  to  hasten 
the  advent  of  full  municipal  control. 


CHAPTER  VIII 

The  Nurse  in  Relation  to  the  Physician — Municipal  Control  of 
Infectious  Diseases — The  Nurse's  Difficulties — A  Waiting 
Policy — Undiagnosed  Cases — The  Nurse's  Responsibility 
to  the  Conscientious  Physician  Only. 

The  Nurse  in  Relation  to  the  Physician.     In  the 

foregoing  chapter,  we  have  seen  that  the  task  of 
preserving  and  improving  the  public  health  is 
one  which  rests,  theoretically,  on  the  medical  pro- 
fession as  a  whole.  As  a  matter  of  fact,  however, 
this  task  is  assumed  only  by  certain  members  of 
the  profession.  We  have  pointed  out  the  reasons 
for  this — that  physicians  vary  greatly  as  to  per- 
sonal character,  ability,  and  ideals.  In  the  field  of 
public  health,  the  nurse  finds  herself  in  contact 
with  physicians  of  all  classes.  Some  are  able, 
high-minded,  and  skilful,  and  whether  working  as 
public  officials  or  private  practitioners,  have  never- 
theless the  same  end ;  improvement  of  the  public 
health.  Others  have  standards  quite  the  reverse. 
This  brings  us  to  the  question :  When  the  nurse's 
duties  bring  her  in  contact  with  men  of  the  latter 
class,  how  is  she  to  meet  the  situation?  In  what 


88  The  Tuberculosis  Nurse 

relation  does  she  stand  to  these  men?  What  shall 
be  her  attitude  to  them,  as  regards  her  work? 
They  are  not  numerous  fortunately,  but  there  are 
enough  to  constitute  a  serious  problem,  and  one 
which  sooner  or  later  the  nurse  must  face.  This 
question  will  also  have  to  be  faced  by  those  who  are 
responsible  for  the  nurse,  and  for  her  work. 

In  our  opinion,  the  answer  is  simple  enough — or, 
rather  it  will  be,  twenty  years  hence.  For  at 
present,  public  opinion  is  in  a  transition  state  and 
needs  moulding.  The  nurse  should  work  under  the 
direction  of,  and  in  co-operation  with,  all  those 
physicians  who,  whether  as  public  officials  or 
private  practitioners,  are  working  for  a  higher 
standard  of  public  welfare.  To  all  such,  without 
discrimination,  the  public-health  nurse  is  the 
faithful,  efficient,  and  tireless  ally.  But  to  all  those 
other  physicians  who  have  no  such  aims  or  desires, 
the  nurse  stands  in  but  remote  and  casual  relation. 
The  old  teaching  that  she  is  the  handmaiden  of  the 
doctor  is  gone.  Both  are  now  co-workers  in  the 
field  of  public  health.  The  nurse  still  carries  out 
the  doctor's  orders,  but  there  is  this  difference- 
she  discriminates  as  to  doctors.  As  a  public 
servant,  she  obeys  the  orders  of  the  municipal 
authorities,  or  of  the  private  practitioner  when  the 
object  of  both  is  the  same,  that  is,  the  welfare  of 


Nurse's  Relation  to  the  Physician     89 

the  community.  But  she  is  not  responsible  to 
those  physicians  who  try  to  defeat  this  object. 

For  this  reason,  the  nurse  can  do  more  effective 
work  if  she  is  connected  with  the  Health  Depart- 
ment, since  it  is  the  Health  Department  of  a  city 
which  must  formulate  standards  of  efficiency,  and 
clothe  its  employees  with  authority  to  carry  them 
out.  The  authority  of  the  Health  Department 
physicians  should  be  superior  to  that  of  any  private 
physician,  should  there  be  any  conflict  of  opinion 
between  them. 

If  the  nurse  cannot  be  established  in  connexion 
with  the  local  Health  Department,  she  will  yet  be 
responsible  to  a  group  of  public- spirited  citizens, 
which  group  will  undoubtedly  include  many  ad- 
vanced and  enlightened  physicians.  This  group 
of  people  will  represent  advanced  public  opinion 
on  the  subject  of  tuberculosis,  and  the  authority 
which  the  nurse  gets  from  them  will  be  of  almost 
equal  value  to  that  which  she  would  get  from  the 
municipality.  Municipal  authority,  or  the  author- 
ity of  enlightened  public  opinion,  is  a  dangerous 
thing  to  oppose. 

Municipal  Control  of  Infectious  Diseases.  In 
the  case  of  smallpox,  diphtheria,  or  scarlet  fever,  the 
private  practitioner  attends  the  patient  under 
the  immediate  supervision  of  the  Health  Depart- 


90  The  Tuberculosis  Nurse 

ment.  Thus,  in  diphtheria  and  scarlet  fever,  he 
notifies  the  Department  of  each  case  that  comes 
under  his  notice.  A  municipal  physician  is  at  once 
sent  to  take  cultures  from  the  patient's  throat,  as 
well  as  from  all  the  other  members  of  the  house- 
hold. He  placards  the  house,  and  instructs  the 
family  in  such  preventive  measures  as  shall  insure 
their  safety  and  that  of  the  community.  The 
patient  is  then  left  in  the  charge  of  the  original 
physician,  who  notifies  the  Health  Department 
when,  in  his  opinion,  the  infection  is  over.  His 
opinion,  however,  is  verified  by  the  municipal 
physician,  who  takes  another  series  of  throat 
cultures,  and  ascertains,  quite  independently, 
whether  or  no  the  danger  is  past.  If  it  is,  he 
orders  the  placard  taken  down,  and  arranges  for 
the  fumigation  of  the  house. 

In  the  case  of  smallpox  much  more  drastic 
measures  are  observed.  The  patient  is  summarily 
removed  to  quarantine,  and  all  those  who  have 
come  in  contact  with  him  are  vaccinated  and  kept 
under  observation  for  a  definite  period.  In  this 
way  the  strong  hand  of  authority  protects  the 
community  from  infection — the  private  physician 
has  been  merely  the  means  of  calling  attention  to 
the  danger.  The  time  will  come,  indeed  it  is 
rapidly  approaching,  when  enlightened  public 


Municipal  Control  of  Disease       91 

opinion  will  demand  this  same  care  in  the  matter 
of  tuberculosis.  By  reason  of  the  chronic  nature 
of  the  disease,  the  care  given  must  include  long- 
continued  supervision,  extending  if  need  be,  over 
months  and  years.  This  supervision  will  be  given 
by  municipal  physicians  and  nurses.  Further- 
more, the  private  practitioner  will  no  more  resent 
this,  nor  consider  it  interference  with  his  private 
business,  than  he  resents  municipal  care  of  small- 
pox or  scarlet  fever.  The  readjustment  of  the 
point  of  view  is  necessarily  slow,  but  it  is  coming, 
none  the  less.  Those  of  us  on  the  firing  line,  how- 
ever, who  daily  witness  the  loss  and  sacrifice  due 
to  this  slow  readjustment,  cannot  but  wish  for 
revolution  instead  of  evolution  in  medical  ethics. 
In  this  chapter,  however,  we  must  deal  with  the 
situation  as  it  exists  today.  The  infectious 
nature  of  tuberculosis  has  become  known  com- 
paratively recently,  hence  we  find  ourselves  con- 
fronted with  a  delicate  and  difficult  situation,  as 
must  always  be  the  case  when  public  opinion  is 
evolving.  Today  if  a  private  physician  forbids 
a  nurse  to  visit  his  patient  (and  for  nurse,  read 
also  Health  Department),  the  present  status  of 
public  opinion  will  usually  uphold  him  in  his 
decision.  It  is  for  us,  therefore,  to  find  out  the 
reasons  which  prompt  him  to  this  decision,  and  to 


92  The  Tuberculosis  Nurse 

lay  them  frankly  before  the  public,  and  let  the 
public  pass  judgment.  In  no  other  way  can 
opinion  be  altered,  or  can  we  gain  for  tuberculosis 
the  same  supervision  and  control  that  we  have 
obtained  for  the  other  infectious  diseases. 

The  Nurse's  Difficulties.  Let  us  take  a  few 
examples  of  the  difficulties  the  nurse  meets.  A 
boy  of  fifteen  had  been  diagnosed  by  the  Phipps 
Dispensary  as  a  moderately  advanced  case,  and 
the  nurse  was  asked  to  follow  him  up.  On  her  first 
visit,  the  patient's  mother  refused  to  let  the  nurse 
enter,  saying  that  her  son  had  since  called  in  a 
private  physician,  who  assured  him  that  the  dis- 
pensary diagnosis  was  all  nonsense.  The  dis- 
pensary man  had  counselled  rest;  the  newcomer 
told  the  mother  to  buy  her  son  a  bicycle  and  let 
him  take  all  the  exercise  he  could.  This  treatment 
was  followed  out,  and,  still  acting  on  the  physi- 
cian's  advice,  the  nurse  was  refused  admission  to 
the  house.  The  mother  was  friendly  enough  when 
they  met  on  the  street,  and  she  even  permitted 
the  nurse  to  stop  and  inquire  for  her  son,  always 
cheerfully  replying  that  he  was  doing  well.  Useless 
as  they  were,  the  nurse  continued  these  visits, 
since  she  was  anxious  to  see  the  outcome  of  the 
case.  Finally,  one  day  six  months  later,  the  mother 
threw  open  the  door,  and  in  deep  distress,  begged 


The  Nurse's  Difficulties  93 

the  nurse  to  come  in.  "Do  what  you  can  for  my 
boy,"  she  pleaded,  and  led  the  way  to  an  upper 
bedroom,  where  the  young  fellow  was  lying  in  a 
moribund  condition.  A  few  days  later  he  died. 
The  mother  bitterly  accused  herself  for  her  folly 
in  refusing  the  disinterested  advice  of  the  dis- 
pensary physician,  and  her  grief,  remorse,  and 
opinions  were  given  wide  circulation  in  the  neigh- 
bourhood. At  no  time  during  his  illness  had  in- 
struction been  given  as  to  the  nature  and  danger 
of  the  disease,  and  not  until  a  week  before  death 
did  the  attending  physician  admit  that  something 
was  seriously  wrong.  In  consequence  of  this 
wrong  diagnosis,  the  boy  lost  his  life,  and  the 
physician's  reputation  was  damaged.  Apparently 
he  had  not  taken  into  sufficient  consideration  the 
risk  of  contradicting  a  diagnosis  that  came  from 
such  an  expert  source. 

In  this  particular  case,  it  was  impossible  for  the 
nurse  to  force  her  way  in,  or  to  do  anything  except 
await  developments.  As  it  happened,  there  was 
no  one  in  the  family  likely  to  become  infected,  since 
the  patient  had  no  brothers  or  sisters,  no  one 
except  his  mother  with  whom  he  came  in  con- 
tact. The  sacrifice  of  this  boy  to  the  ignorance, 
obstinacy,  jealousy,  or  stupidity  of  the  local  phy- 
sician proved  a  striking  object  lesson  to  the  neigh- 


94  The  Tuberculosis  Nurse 

bourhood.  The  bereaved  and  indignant  mother 
was  a  factor  in  forming  public  opinion  in  this 
particular  vicinity. 

Another  case  is  that  of  a  woman  who  had  in  her 
employ  a  favourite  coloured  servant,  whom  she 
suspected  to  be  tuberculous.  Accordingly,  she 
sent  for  the  nurse,  asking  her  to  take  all  necessary 
steps  towards  getting  the  case  diagnosed.  As  the 
patient  was  too  ill  to  go  to  a  dispensary  and  could 
not  afford  a  doctor,  the  nurse  brought  a  specimen 
of  sputum  to  the  laboratory  of  the  Health  Depart- 
ment, where  it  was  proved  positive.  So  far,  all  was 
clear  going.  The  patient  was  given  her  prophylac- 
tic supplies,  put  to  bed  in  a  clean,  airy  room,  and 
the  nurse  called  daily  to  give  her  a  bath  and  such 
attention  as  she  required.  This  should  have  been 
a  hospital  case,  but  at  that  time  the  hospital  was 
crowded  and  there  was  no  available  bed.  One 
day,  when  the  nurse  called  as  usual,  she  found  the 
patient  suddenly  become  very  impudent.  She 
was  lying  in  a  room  with  all  windows  closed,  and 
a  coal  oil  stove  in  full  blast;  no  supplies  were  in 
sight  and  the  patient  was  expectorating  at  random 
over  the  floor.  This  change  had  occurred  because 
the  patient  had  taken  some  of  the  money  given  by 
her  employer,  and  had  called  in  a  "private  doc- 
tor," who  declared  she  had  nothing  but  a  passing 


The  Nurse's  Difficulties  95 

cold.  He  also  told  her  the  supplies  were  nonsense, 
and  that  he  could  cure  her  in  two  or  three  weeks. 
Furthermore,  this  physician  himself  came  down 
to  the  Health  Department,  and  forbade  the  nurse 
to  continue  her  visits,  and  all  "interference"  with 
his  case.  A  few  days  later,  the  employer  also  came 
to  the  Health  Department,  in  considerable  heat, 
and  wished  to  know  why  the  nurse  was  neglecting 
her  duty.  The  explanation  was  satisfactory,  and 
a  visit  to  her  servant  amply  corroborated  the 
statements  that  had  been  made.  This  woman  had 
been  paying  her  servant  full  wages  while  off  duty, 
as  well  as  providing  her  with  many  little  luxuries 
and  necessities.  She  was  therefore  in  a  position 
to  dictate  the  terms  upon  which  she  would  con- 
tinue this  assistance,  and  these  terms  did  not 
include  visits  from  a  physician  of  the  calibre  of  the 
man  now  in  attendance.  In  every  case,  however, 
it  is  not  so  easy  to  obtain  the  whip-hand  of  the 
situation. 

In  these  two  instances,  there  was  little  danger  of 
spreading  the  infection,  since  neither  patient  was 
in  close  contact  with  children,  or  other  persons 
likely  to  contract  the  disease.  The  young  boy 
suffered  an  early  death,  while  the  coloured  woman 
suffered  personal  inconvenience  and  discomfort, 
due  to  lack  of  nursing,  care,  and  attention.  In 


96  The  Tuberculosis  Nurse 

neither  case,  however,  was  there  danger  to  other 
people.  Whenever  other  people  are  involved,  it  is 
less  easy  to  stand  by  and  do  nothing,  while  wait- 
ing for  that  slow  change  in  public  sentiment  which 
shall  give  one  the  right  to  interfere.  Thus,  a  phy- 
sician diagnosed  a  case  as  tuberculous,  and  asked 
the  nurse  to  take  charge  of  the  patient,  telling  her 
that  he  had  carefully  examined  all  the  other 
members  of  the  family,  and  found  them  in  appar- 
ently good  condition.  He  added,  however,  that 
he  had  been  dismissed  as  soon  as  he  had  told  the 
family  the  disease  from  which  the  patient  was 
suffering.  For  this  reason,  he  feared  the  nurse 
would  find  difficulty  in  entering  the  home.  His 
fears  were  only  too  well  grounded.  The  family  had 
straightway  called  in  another  doctor,  who  calmed 
their  anxiety  by  denying  the  previous  diagnosis. 
He  also  advised  them  to  turn  away  the  nurse, 
which  they  did. 

The  patient  lived  some  eight  months  after  this, 
during  which  time  she  was  given  no  supplies,  no 
instructions  of  any  sort,  and  the  family  were  kept 
in  ignorance  of  the  nature  of  her  illness.  When 
she  died,  the  nufse  as  agent  of  the  Health  Depart- 
ment went  to  the  house  to  arrange  for  the  fumiga- 
tion. The  front  door  was  opened  by  a  young  girl 
obviously  tuberculous — the  nurse  was  struck  with 


A  Waiting  Policy  97 

her  appearance;  further  search  revealed  still  an- 
other member  of  the  household  who  presented 
suggestive  symptoms.  In  their  distress,  the  fam- 
ily turned  to  the  nurse  and  asked  for  advice  and 
assistance,  and  she  at  once  referred  them  to  the 
physician  who  had  diagnosed  the  original  patient, 
eight  months  ago.  The  family  obediently  pre- 
sented themselves  to  him,  and  he  found  that 
three  more  members  had  become  infected.  Since 
they  were  all  in  the  early  stages,  it  is  probable 
that  they  had  become  infected  during  the  last 
few  months  of  the  patient's  life — during  which 
time  not  one  precautionary  measure  had  been 
observed.  The  day  will  surely  come  when  the 
possibility  of  treating  tuberculosis  lightly,  at  the 
option  of  the  attending  physician,  will  not  be 
allowed.  Public  sentiment  will  finally  insist 
upon  full  municipal  control,  which  will  do  away 
with  such  malpractice  and  sacrifice  of  human 
life. 

A  Waiting  Policy.  As  matters  stand  today,  we 
can  do  nothing  but  accept  the  situation  as  we  find 
it,  and  do  the  best  that  circumstances  will  permit. 
Which  brings  us  to  the  question  of  the  hour — What 
is  to  be  done  if  the  physician  refuses  to  let  the 
nurse  visit  his  patient?  Is  she  to  accept  his  dis- 
missal and  turn  away,  or  is  she  to  continue  her 


98  The  Tuberculosis  Nurse 

visits  in  spite  of  his  objections,  on  the  ground  that 
the  patient  is  hers  as  well  as  his? 

If  the  case  is  a  positive  one,  diagnosed  on  un- 
questionable authority,  and  if  the  nurse  has  been 
sent  by  a  dispensary,  the  Federated  Charities,  or 
through  some  other  disinterested  source,  she  should 
be  readily  able  to  gain  admission.  Having  gained 
this,  she  should  be  able  to  hold  her  own  against  all 
comers.  As  a  rule,  it  is  the  opposition  she  encoun- 
ters before,  rather  than  after  her  first  visit,  which 
determines  her  ability  to  do  her  work  in  the  home. 
Once  in  the  home,  however,  it  should  make  little 
difference  whether  or  not  the  patient  changes 
doctors.  If  he  does,  she  should  continue  her  visits 
as  usual — her  knowledge  of  his  condition  makes  it 
advisable  to  hang  on  to  the  family  at  all  costs.  If 
this  change  brings  a  friendly  doctor,  he  will  not 
object  to  the  nurse.  If  it  brings  a  prejudiced  one, 
she  should  do  nothing  to  excite  his  hostility. 
Thus,  if  the  new  doctor  denies  the  presence  of 
tuberculosis,  it  may  become  necessary  for  her  to 
seem  to  assent  to  this  opinion — for  a  time  she  may 
have  to  visit  merely  in  the  capacity  of  a  friend, 
offering  no  advice,  and  distributing  no  supplies. 
She  must  be  careful  not  to  antagonize  the  family, 
for  after  all,  it  is  the  family,  at  the  doctor's  instiga- 
tion, which  is  able  to  turn  her  out.  Thus,  when 


Undiagnosed  Cases  99 

they  triumphantly  tell  her  that  the  patient  no 
longer  has  consumption,  she  should  not  contradict 
them.  Time  will  do  it  for  her.  She  may  express 
pleasure  at  the  happy  change,  and  ask  for  permis- 
sion to  stop  in  now  and  then,  in  passing,  in  the 
capacity  of  an  old  acquaintance.  This  request  will 
seldom  be  denied,  and  at  all  costs  she  must  keep 
in  touch  with  the  family  which  now,  more  than 
ever,  needs  her  supervision  and  aid.  She  must 
stand  by,  ready  to  give  this  as  soon  as  it  is  wanted. 
During  this  time  it  will  be  very  hard  to  wait,  to  see 
the  patient  relax  all  vigilance,  and  to  see  the 
family  recklessly  exposed.  But  this  waiting  policy 
will  pay  in  the  end.  As  we  have  said  elsewhere, 
the  consumptive  changes  doctors  more  often  than 
any  other  class  of  patients,  and  the  nurse  must 
realize  this,  and  be  ready  to  follow  him  through 
the  vicissitudes  which  these  changes  involve.  She 
must  avoid  all  criticism  when  the  family  is  fallen 
upon  evil  times,  and  be  ready  to  uphold  and  en- 
courage them  when  they  are  fallen  upon  good 
times. 

Undiagnosed  Cases.  In  the  matter  of  suspected 
or  undiagnosed  cases,  there  is  greater  difficulty. 
In  these  cases  the  nurse  has  nothing  to  go  on  but 
her  own  keen  observation  of  symptoms,  therefore 
the  physician  in  charge  may  make  it  very  difficult 


TOO          The  Tuberculosis  Nurse 

for  her  to  continue  her  visits.  He  can  withhold 
his  diagnosis,  ignorantly  or  wilfully,  and  there  is 
nothing  to  do  but  to  accept  this  state  of  affairs. 
As  before,  the  nurse  must  quietly  hold  on  to  the 
case,  saying  nothing  that  can  possibly  imply  criti- 
cism or  involve  her  in  difficulty  with  the  doctor. 
Time  must  be  trusted  to  clear  the  situation — 
either  the  patient  will  get  better,  or  he  will  get  so 
much  worse  that  a  diagnosis  may  be  forthcoming. 
Or  else  he  may  change  doctors.  When  a  nurse  is 
visiting  a  case  in  charge  of  one  doctor,  she  must  be 
exceedingly  careful  never  to  advise  another  or  to 
suggest  a  dispensary.  All  this  involves  infinite 
waste  of  time  and  loss  of  life,  but  as  matters  stand 
today,  there  is  no  other  course  to  pursue.  When 
a  nurse  is  visiting  a  case  of  this  kind — it  may  be 
one  who  presents  every  symptom  of  tuberculosis, 
including  even  hemorrhage- — she  must  be  particu- 
larly careful.  She  may  call  up  the  doctor,  tell  him 
that  she  has  been  called  to  his  case  through  such 
and  such  an  agency  (these  cases  are  usually  re- 
ferred by  a  layman)  and  ask  if  there  are  any  orders 
he  would  like  carried  out.  She  may  also  ask  him  to 
tell  her  the  nature  of  the  disease.  If  he  refuses,  it 
is  then  a  question  of  further  "watchful  waiting." 
If  the  patient  is  expectorating  a  great  deal,  she 
may  provide  him  with  a  sputum  cup  and  other 


Undiagnosed  Cases  101 

supplies,  taking  care,  however,  never  to  use  the 
word  " tuberculosis"  in  connection  with  them. 
She  simply  offers  them  as  a  convenience  for  a  dis- 
tressing symptom.  We  have  known  patients  of 
this  kind  who  died  after  being  ill  for  months,  most 
of  the  time  being  spent  in  bed.  Meanwhile,  they 
had  extreme  emaciation,  night  sweats,  fever,  cough, 
profuse  expectoration,  even  hemoptysis,  yet  the 
death  certificate  read  "bronchitis."  It  is  true, 
that  these  patients  may  really  have  died  of  bron- 
chitis; as  nurses,  we  cannot  make  diagnoses, 
therefore  we  have  no  right  to  question  the  phy- 
sician's findings.  But  it  is  impossible  for  an  in- 
telligent nurse  to  look  on  at  a  case  of  this  kind 
without  wishing  it  were  possible  to  obtain  a  second 
opinion.  As  public  health  nurses  we  cannot  but 
object  that  the  last  word  on  so  serious  a  disease 
should  be  said  by  men  whose  diagnoses  we  dis- 
trust. That  the  health  of  the  community  should 
be  endangered  by  even  a  few  physicians  of  this 
sort, — either  ignorant,  or  dishonest,  or  both, — is 
grave  commentary  upon  the  medical  ethics  of  the 
day.  It  is  a  severe  criticism  on  that  "professional 
courtesy"  which  forbids  intervention,  even  by  the 
health  authorities,  with  a  physician  who  drives 
his  trade  at  the  community's  expense.  The  war 
against  tuberculosis  cannot  be  fought  to  a  success- 


io2          The  Tuberculosis  Nurse 

ful  finish  until  the  public  refuses  to  countenance 
ethics  of  this  sort. 

The  Nurse's  Responsibility  to  the  Conscientious 
Physician  Only.  In  all  tuberculosis  work,  the 
nurse  is  singularly  independent.  When  the  patient 
is  in  charge  of  the  dispensary  physician,  or  is  in 
charge  of  a  doctor  in  sympathy  with  the  tubercu- 
losis movement,  she  may  be  said  to  be  acting 
under  their  orders.  Or  rather,  there  are  no  special 
orders,  except  in  individual  instances,  for  the 
routine  prescribed  is  always  practically  the  same. 
When  a  doctor  reports  a  case,  with  the  laconic 
statement,  "John  Smith,  such  and  such  an  address, 
usual  thing,"  he  has  fully  stated  the  situation. 
The  doctor  knows  what  should  be  done,  and  the 
nurse  knows  what  to  do,  and  further  words  are 
unnecessary.  Therefore,  when  for  any  reason  the 
patient  gives  up  his  doctor,  the  nurse  can  still 
continue  to  supervise  and  direct.  Months  may 
pass  before  the  patient  revisits  a  physician,  and 
during  these  months  the  nurse  is  the  only  person 
in  touch  with  him.  She  also  knows  how  to  advise 
and  direct  those  who  are  in  contact  with  him. 
When  he  finally  calls  upon  a  doctor  again,  her 
visits  still  continue  without  a  break — there  should 
be  nothing  in  her  teaching  that  is  at  variance  with 
that  of  the  newly  arrived  physician.  The  chronic 


The  Nurse's  Responsibility        103 

nature  of  tuberculosis  makes  this  situation  possi- 
ble, and  also  makes  for  the  extremely  independent 
position  of  the  nurse. 

Whenever  the  physician  is  in  the  vanguard  of 
the  an ti- tuberculosis  movement,  he  will  recognize 
the  nurse  as  an  ally,  not  a  rival.  He  will  know 
that  she  will  make  no  attempt  to  supplant  him 
with  the  patient,  since  the  chances  are  that  she  has 
been  caring  for  the  patient  for  months  before  he, 
the  doctor,  has  been  called  in.  He  will  regard  her, 
therefore,  as  a  highly  efficient  ally,  who  will  relieve 
him  of  tiresome,  time-consuming  details  connected 
with  the  case.  She  will  take  charge  of  routine 
matters  that  he  has  no  time  for,  and  thus  set  him 
free  for  larger  and  more  important  tasks. 

If,  on  the  contrary,  the  physician  is  one  who 
exploits  his  patients,  who  keeps  the  nature  of  the 
disease  hidden,  whether  through  ignorance  or  de- 
sign, and  fails  to  give  proper  instruction  as  to  its 
infectiousness,  then  we  must  look  for  nothing  but 
opposition  and  antagonism.  We  must  hear  ob- 
jections as  to  the  nurse's  interference,  to  her  uni- 
form, to  her  tactlessness,  to  her  scaring  the  patient 
to  death — and  we  must  consider  the  motives  which 
underlie  them.  This  brings  us  once  more  to  the 
question — under  these  circumstances,  what  is  the 
nurse  to  do?  Is  she  to  discontinue  her  visits,  or  is 


104          The  Tuberculosis  Nurse 

the  value  of  her  instruction  to  be  nullified  by 
contradictory  advice?  Is  a  physician,  who  has 
consideration  for  neither  the  patient  nor  the 
community  to  be  allowed  to  jeopardize  both? 

To  men  of  this  stamp,  the  tuberculosis  nurse 
owes  nothing.  Her  business  is  to  do  her  duty,  even 
when  it  brings  her  to  cross-purposes  with  them. 
She  has  been  taught  her  work  by  the  most  ad- 
vanced and  progressive  members  of  the  medical 
profession,  and  in  the  homes  of  patients  she  is  but 
carrying  out  the  orders  of  these  abler  men.  That 
they  themselves  may  have  no  direct  connection 
with  the  patient  does  not  alter  the  situation.  She 
is  their  agent,  not  the  agent  of  the  hold-overs  from 
a  passing  regime.  Therefore,  we  look  to  the 
former  to  establish  their  agent,  the  public-health 
nurse,  in  a  position  of  unassailable  dignity  and 
authority. 


CHAPTER  IX 

Obtaining  a  Diagnosis — The  General  Dispensary — Sputum  Ex- 
aminations— Tuberculin  Tests — Registration  of  Cases. 

Obtaining  a  Diagnosis.  As  we  all  know,  it  is 
not  the  business  of  the  nurse  to  make  diagnoses, 
but  it  is  emphatically  her  business  to  select  cases 
which  should  be  diagnosed,  and  to  send  them 
where  this  may  be  done.  Therefore,  if  a  commun- 
ity supports  a  tuberculosis  nurse  it  will  also  find  it 
necessary  to  establish  a  place  where  she  may  send 
her  patients  for  examination — a  special  dispensary 
for  the  recognition  of  pulmonary  tuberculosis.  If 
there  is  no  such  dispensary,  in  charge  of  a  capable 
physician,  she  may  find  it  exceedingly  difficult  to 
obtain  a  diagnosis  for  her  patients,  without  which 
her  hands  are  tied.  She  cannot  preach  fresh  air 
and  prophylaxis  to  a  person  who  has  nothing  but  a 
"heavy  cold,"  no  matter  how  serious  may  be  the 
symptoms  in  connection  with  it.  If  the  physician 
in  charge  of  such  a  case  is  unable  or  unwilling  to 
make  a  diagnosis,  it  is  necessary  to  have  some 

court  of  appeal  to  which  the  patient  may  be  sent 

105 


io6          The  Tuberculosis  Nurse 

the  moment  he  gives  up  his  doctor  or  his  doctor 
gives  him  up.  As  we  have  said  before,  the  nurse 
must  never  influence  a  patient  to  change  his  doc- 
tor— on  the  contrary,  she  must  be  exceedingly 
punctilious  in  this  regard — but  when  the  patient 
is  fickle  and  inconstant  in  his  allegiance,  she  must 
take  advantage  of  the  opportunities  offered  to 
send  him  where  he  may  be  skilfully  examined. 
The  question  of  the  special  dispensary  will  be 
treated  more  fully  in  another  chapter  —  here  it 
is  simply  our  purpose  to  show  the  need  of  such  a 
place. 

In  a  community  which  is  beginning  tuberculosis 
work,  there  are  usually  a  few  physicians  who  will 
generously  volunteer  their  services  in  examining 
suspected  cases.  The  nurse,  however,  will  feel 
some  hesitation  in  accepting  these  kindly  offers, 
since  to  take  full  advantage  of  them  would  be  to 
swamp  these  physicians  with  a  class  of  patients 
which  would  leave  them  but  little  time  for  their 
private  practice.  These  offers,  however,  may  well 
be  utilized  in  the  formation  of  a  special  dispensary, 
since  the  same  men  would  doubtless  be  equally 
willing  to  examine  patients  at  some  central  locality. 
No  matter  how  humble  the  quarters,  how  imper- 
fect the  equipment,  it  is  necessary  to  establish  as 
soon  as  possible  a  special  place  where  these  patients 


The  General  Dispensary          107 

may  be  freely  examined  without  any  sense  of 
intrusion  or  of  incurred  obligation. 

The  General  Dispensary.  In  many  cities,  gen- 
eral dispensaries  exist  for  the  treatment  of  minor 
medical  and  surgical  diseases.  It  is  possible  to 
send  tuberculous  patients  to  these  dispensaries, 
and  to  get  them  examined  and  diagnosed,  but  as  a 
rule  this  is  not  satisfactory.  These  general  dis- 
pensaries are  usually  crowded,  and  the  physicians 
in  charge  are  unable  to  give  sufficient  time  to  the 
protracted,  careful  examination  which  the  con- 
sumptive requires.  However,  failing  a  special 
dispensary,  the  nurse  must  take  advantage  of 
these  general  clinics  and  accept  all  the  help  they 
are  able  to  give. 

Sputum  Examinations.  In  many  States,  the 
local  or  State  Departments  of  Health  maintain 
laboratories  for  the  examination  of  sputum.  The 
nurse  as  well  as  the  doctor  should  be  allowed  the 
privilege  of  sending  specimens  for  examination. 
If  the  findings  are  positive,  the  result  is  a  diagnosis 
from  which  there  can  be  no  appeal.  The  difficulty 
with  this  means  of  diagnosis,  however,  is  that 
many  specimens  are  negative  upon  first  examina- 
tion. It  may  require  repeated  examinations  to  find 
the  bacilli,  or  before  their  continued  absence  may 
be  considered  evidence  that  the  patient  is  not 


io8         The  Tuberculosis  Nurse 

tuberculous.  Dr.  Victor  F.  Cullen,  Superintendent 
of  the  Maryland  Tuberculosis  Sanatorium,  writes : 

"  We  had  one  case  that  was  examined  sixty-seven 
times  before  tubercle  bacilli  were  found,  and  this 
was  a  far  advanced  case,  with  both  lungs  involved 
from  top  to  bottom,  and  cavities  in  each  lung. 

"We  have  at  the  present  time  (September  14, 
1914)  a  patient  in  the  Sanatorium,  with  both  lungs 
diffusely  involved,  with  a  huge  cavity  in  her  left 
lung,  expectoration  about  two  boxes  daily,  whose 
sputum  was  examined  twenty -four  times,  with  only 
three  positive  findings. 

"These  advanced  cases  with  a  lot  of  bronchial 
secretion  are  usually  the  ones  in  which  it  is  difficult 
to  find  tubercle  bacilli  in  one  or  two  examinations. " 

The  nurse,  therefore,  should  send  in  specimens 
frequently,  every  week  or  so,  and  should  never  be 
satisfied  with  a  negative  report.  As  we  have  said 
before,  finding  the  bacilli  is  proof  positive  that  the 
patient  has  tuberculosis,  but  not  finding  them  is  no 
proof  to  the  contrary.  Countless  lives  have  been 
sacrificed  by  considering  a  negative  return  as 
evidence  that  the  patient  was  not  tuberculous. 

The  nurse  should  carry  in  her  satchel  specimen 
bottles  for  collecting  sputum.  These  bottles  are 
provided  by  the  Health  Department.  If  the 
nurse  has  been  called  to  a  patient  by  the  Federated 


vSputum  Examinations  109 

Charities,  or  through  some  similar  source,  or  if  the 
patient  is  one  whom  she  herself  has  discovered, 
she  may  send  the  specimen  to  the  laboratory  on 
her  own  initiative.  But  if  the  patient  is  already 
under  the  care  of  a  physician  who  has  not  made 
a  diagnosis,  the  nurse  may  call  upon  him  and  ask 
if  she  may  take  such  a  specimen  to  be  examined. 
This  courtesy  will  doubtless  ensure  better  co- 
operation and  understanding,  but  if  the  physician 
refuses>  the  nurse  is  then  in  an  awkward  position. 
In  a  short  time  she  will  learn  the  various  physicians 
of  her  district,  those  whom  she  may  call  upon,  and 
those  whom  she  may  not,  and  she  will  learn  to 
exercise  considerable  discretion  concerning  them. 

Valuable  as  these  sputum  examinations  may  be 
in  the  case  of  a  positive  finding,  they  should  never 
take  the  place  of  a  careful  physical  examination. 
It  is  only  when  this  examination  is  not  to  be  had, 
when  the  diagnosis  can  be  obtained  in  no  other  way, 
that  the  nurse  will  be  obliged  to  rely  upon  sputum 
examinations  alone  in  dealing  with  her  patients. 
A  positive  sputum  should  confirm  the  diagnosis 
made  by  physical  examination — it  is  not,  or  should 
not  be,  the  only  means  of  obtaining  this  diagnosis. 
Therefore,  the  fact  that  a  Health  Department  is 
equipped  to  make  sputum  examinations  should 
never  for  a  moment  supplant  the  dispensary,  in 


i  io          The  Tuberculosis  Nurse 

charge  of  a  specialist  or  expert.  A  specialist  is 
able  by  auscultation,  percussion,  and  an  ear  finely 
trained  to  detect  changes  in  the  breath  sounds, 
and  to  recognize  tuberculosis  weeks  before  the 
diagnosis  is  confirmed  by  sputum  findings.  In  this 
way  it  is  possible  to  place  a  patient  under  treat- 
ment long  in  advance  of  the  time  when  the  average 
physician  would  have  recognized  the  disease — an 
advantage  to  the  patient  and  to  the  community  as 
well. 

Tuberculin  Tests.  There  are  two  tuberculin 
tests  commonly  used,  which  enable  the  specialist 
to  diagnose  doubtful  cases.  These  are  the  eye  and 
the  skin  test.  Strictly  speaking,  the  public-health 
nurse  has  nothing  to  do  with  these  tests,  since  they 
are  entirely  within  the  realm  of  the  physician,  but 
she  should  at  least  understand  their  significance. 
The  Von  Pirquet,  or  Skin  Test,  consists  of  inocu- 
lating the  forearm  with  a  drop  of  tuberculin  of  a 
certain  strength.  A  positive  reaction  is  manifest 
by  a  slight  redness  appearing  within  twenty-four 
hours  and  this  may  persist  for  a  day  or  two,  after 
which  it  disappears.  This  test  has  no  value  in  the 
case  of  adults,  since  all  adults  are  supposed  to 
possess  some  slight  tuberculous  focus,  and  there- 
fore a  reaction  has  no  significance.  In  the  case  of 
children,  however,  a  positive  skin  test  has  some 


Registration  of  Cases  in 

value.  Children  are  not  as  a  matter  of  course  sup- 
posed to  possess  tubercular  foci,  and  a  positive 
reaction  would  therefore  indicate  that  they  have 
become  infected.  A  reaction,  however,  gives  no 
indication  as  to  the  location  of  the  focus — it  only 
proves  its  existence. 

The  Calmette,  or  Eye  Test,  has  more  impor- 
tance. A  drop  of  tuberculin  is  placed  inside  the 
lower  eyelid  of  one  eye,  and  if  a  reaction  occurs,  it 
does  so  within  twenty-four  hours.  The  conjunc- 
tiva becomes  slightly  red  and  inflamed,  which 
condition  persists  for  a  day  or  two  and  then  dis- 
appears. In  adults  as  well  as  children,  this  is  a 
positive  indication  of  tuberculosis — not  necessarily 
of  a  mere  latent  focus,  but  of  a  possible  lesion 
which  must  be  watched  and  guarded  against.  It 
gives  no  indication,  however,  of  the  location  of  the 
lesion. 

These  tests  are  useful  to  specialists  in  helping 
them  to  highly  refined  diagnoses.  Dr.  Hamman, 
however,  questions  the  validity  of  these  extremely 
early  diagnoses,  unless  they  are  confirmed  by 
sputum  findings.  If  the  bacilli  are  not  found  the 
diagnosis  rests  entirely  with  the  examiner,  and  is 
therefore  dependent  upon  the  personal  equation. 

Registration  of  Cases.  Most  States  have  laws 
which  require  the  notification  of  infectious  dis- 


ii2          The  Tuberculosis  Nurse 

eases,  including  tuberculosis.  This  means  that  all 
physicians  are  required  to  report  their  cases  of 
tuberculosis  to  the  Health  Department,  filling  in  a 
card,  more  or  less  complex,  in  which  is  set  forth  the 
patient's  name,  age,  address,  occupation,  and  the 
duration  and  stage  of  the  disease.  In  Baltimore, 
the  nurses  also  are  allowed  to  register  their  tu- 
berculous patients  in  this  way,  with  the  city  as 
well  as  the  State  Health  Department.  The  card 
used  is  the  same  as  that  used  by  the  physicians, 
but  with  this  difference — since  a  nurse  is  unable  to 
make  a  diagnosis  herself,  she  is  required  to  place 
in  the  corner  of  the  card  the  name  and  address  of 
the  physician  or  dispensary  responsible  for  the 
diagnosis.  In  this  way  the  authorities  are  enabled 
to  know  how  many  patients  are  under  the  nurses' 
supervision,  and  the  sources  of  the  diagnosis. 

Many  of  these  registration  cards  are  duplicates, 
the  case  having  already  been  registered  by  the 
attending  physician,  or  the  dispensary.  If  they 
are  not  duplicates,  it  is  necessary  to  have  the 
official  registration  in  the  handwriting  of  the 
physician  himself — it  is  often  needed  when  trouble 
arises  over  the  fumigation  of  houses,  and  so  forth. 
There  is  nothing  official  or  authoritative  about  the 
nurse's  registration  cards — these  merely  call  atten- 
tion to  the  fact  that  certain  patients  are  under  her 


Registration  of  Cases  113 

supervision,  attended  by  such  and  such  a  doctor. 
In  most  cases,  the  diagnosis  given  is  a  verbal  one. 
Should  any  difficulty  arise,  this  verbal  diagnosis 
would  not  be  valid,  although  it  furnishes  an  excel- 
lent basis  from  which  to  instruct  the  patient  and 
his  family.  Therefore  the  nurse's  registration 
card,  if  it  is  not  a  duplicate,  serves  to  call  attention 
to  the  fact  that  a  certain  physician  is  in  charge  of  a 
case  which  he  has  not  reported.  The  Health 
Department  at  once  writes  and  asks  him  to  report, 
and  in  this  way  the  diagnosis  is  officially  recorded. 
In  Maryland,  the  law  calling  for  the  registration 
of  tuberculosis  had  been  on  the  statute  books  some 
years,  but  was  generally  disregarded.  The  phy- 
sicians failed  to  report  their  cases,  and  it  was 
therefore  impossible  to  estimate  the  amount  or 
distribution  of  tuberculosis.  To  do  this  was  the 
object  of  the  law.  How  generally  this  regulation 
had  been  ignored  may  be  judged  from  the  fact 
that  in  1909,  the  year  before  the  Baltimore  munici- 
pal nurses  went  on  duty,  the  number  of  cases  of 
tuberculosis  registered  by  physicians  was  only  919, 
while  the  deaths  from  tuberculosis  for  that  same 
year  were  1400.  In  1910,  the  first  year  that  the 
nurses  were  on  duty,  the  cases  registered  jumped 
up  to  3202,  while  the  deaths  fell  to  1234.  This 
sudden  increase  in  the  registrations — an  increase 


ii4          The  Tuberculosis  Nurse 

of  over  three  hundred  per  cent. — shows  the  stimu- 
lating effects  of  a  staff  of  active  public-health 
nurses. 

How  necessary  it  is  to  have  the  diagnosis  re- 
corded in  the  physician's  own  handwriting  may 
be  judged  by  the  following  incident.  There  was 
a  coloured  man  on  our  list,  referred  to  us  by  a 
private  physician.  This  patient  was  a  model  in  a 
school  of  painting  and  drawing,  and  after  a  time 
the  Health  Department  was  flooded  with  com- 
plaints concerning  him.  These  complaints  came 
from  pupils,  who  declared  they  were  afraid  to  go  to 
the  classes,  because  the  patient  coughed  so  vio- 
lently and  spat  so  profusely.  The  students  did  not 
know  he  was  tuberculous,  but  they  suspected  it, 
and  therefore  asked  us  to  look  into  the  matter. 
Finding  that  the  man  was  one  of  our  patients,  we 
at  once  wrote  to  the  directors  of  this  school, 
telling  them  of  this,  and  of  the  complaints  that 
had  been  made  against  him.  We  further  suggested 
that  if  he  continued  to  pose  as  a  model  he  should 
use  the  prophylactic  supplies  that  the  nurse  had 
given  him,  and  which  he  used  faithfully  enough  in 
his  own  home.  The  Directors,  however,  would  not 
take  our  word  for  this;  they  sent  the  patient  to 
another  physician,  not  the  one  who  had  originally 
examined  him.  To  this  man,  the  darkey  protested 


Registration  of  Cases  115 

that  he  had  never  seen  a  doctor  in  his  life.  The 
second  physician  declared  that  the  patient  did  not 
have  tuberculosis,  wrote  a  note  berating  us  for  our 
interference,  and  called  upon  us  for  proof.  A  hur- 
ried search  of  the  files  brought  forth  the  original 
registration  card,  sent  in  by  the  physician  who  had 
first  diagnosed  the  case,  and  transferred  it  to  the 
nurses  of  the  Health  Department.  This  fact  at 
once  threw  a  different  light  upon  the  matter,  and 
we  were  able  to  uphold  our  contention.  The  first 
physician,  however,  had  completely  forgotten  this 
patient,  and  had  it  not  been  for  his  registration 
card,  on  file  at  the  office,  we  should  have  been  in  a 
very  disagreeable  position. 

Since  there  is  nothing  authoritative  about  the 
nurse's  registration  card,  she  must  be  exceedingly 
careful  never  to  register  a  case  unless  it  has  been 
properly  diagnosed.  This  information  should  be 
obtained  from  the  physician  himself,  whether  in 
writing,  verbally,  or  over  the  telephone.  She 
should  never  accept  a  third  person's  word  for  the 
diagnosis,  no  matter  how  accurate  it  may  seem. 
For  example,  if  a  patient's  mother  tells  the  nurse 
that  the  doctor  has  just  been  in,  and  said  her  son 
had  tuberculosis,  the  nurse  must  not  accept  this 
statement  as  sufficient.  She  must  call  upon  the 
physician  and  ask  him  herself.  Again,  suppose  the 


n6          The  Tuberculosis  Nurse 

nurse  has  sent  a  patient  to  the  dispensary,  and, 
meeting  him  on  the  street  an  hour  later,  she  learns 
that  the  doctor's  verdict  was  consumption.  She 
must  not  take  the  patient's  word  for  this,  obvious 
as  its  truthfulness  may  seem.  It  is  necessary  to 
be  thus  punctilious,  to  prevent  unpleasant  oc- 
currences from  taking  place.  The  diagnosis  of 
tuberculosis  is  too  serious  a  matter  to  be  accepted 
through  any  such  irresponsible  medium  as  the 
patient  or  his  family. 

To  fill  in  the  registration  cards  is  the  nurse's 
work.  To  supervise  these  cards,  and  note  their 
correctness  and  accuracy,  should  be  the  work  of 
the  superintendent  of  nurses,  in  whose  name  they 
should  be  signed.  This  transaction  is  one  of  the 
most  important  tasks  of  the  office,  and  extreme 
care  should  be  taken  that  non-tuberculous  patients 
are  not  registered  by  mistake. 


CHAPTER  X 

Prevention  of  Tuberculosis — Sources  through  Which  Calls  are 
Received— Entering  the  Home— Telling  the  Truth  to  the 
Patient — Truth  for  the  Family — Disposal  of  Sputum — 
Danger  of  Expired  Air — Isolation  of  Dishes —  Linen,  House- 
hold and  Personal — Disinfectant  and  Other  Supplies — 
Phthisiphobia. 

The  Prevention  of  Tuberculosis.  The  object 
of  the  nurse's  work  is  to  prevent  the  spread  of 
tuberculosis — it  is  not  to  cure  the  disease.  In 
doing  the  preventive  work,  it  often  follows  that 
the  patient  himself  is  immensely  benefited,  and 
his  disease  apparently  arrested.  This  arrest,  how- 
ever, is  incidental — it  is  not  the  real  object  of  the 
work,  which  is  the  protection  of  individuals  as 
yet  uninfected.  In  no  other  branch  of  nursing  is 
there  so  much  misunderstanding,  so  much  placing 
of  the  cart  before  the  horse,  and  so  much  emphasis 
laid  on  the  wrong  thing.  Nurses  themselves 
when  they  first  begin  the  work  fail  to  recognize 
the  real  issue,  and  think  that  it  is  the  actual  care 
of  the  patient  which  is  the  thing  to  be  considered. 
This  is  totally  wrong — we  work  through  the 

117 


n8         The  Tuberculosis  Nurse 

patient  to  gain  our  ends,  but  he  himself  is  not  the 
main  object.  It  is  necessary  to  grasp  this  fact 
firmly,  and  keep  it  constantly  in  mind.  This 
will  not  only  prevent  much  disappointment  and 
discouragement,  but  it  will  lay  the  foundation  for 
more  intelligent  work. 

On  entering  the  home  of  the  consumptive,  the 
nurse  has  before  her  two  responsibilities,  the 
family  and  the  patient.  The  former  is  infinitely 
larger  and  more  important,  since  it  is  the  family, 
as  yet  uninfected,  which  must  be  protected  from 
the  patient,  or  source  of  the  disease.  Instead  of 
"  family"  substitute  the  word  "community" 
and  we  have  the  crux  of  the  situation — the  pro- 
tection of  the  community  from  the  danger  to 
which  it  is  exposed.  This  protection  may  be 
accomplished  largely  through  care  of  the  patient, 
but  care  of  the  patient,  only,  as  such,  is  a  secondary 
matter.  The  vital  and  important  concern  is  the 
welfare  of  his  family.  To  confuse  these  two  issues, 
and  put  the  patient  first,  and  the  family,  which 
means  the  community,  second,  would  delay 
indefinitely  the  result  we  hope  to  attain.  As 
far  as  possible,  the  interests  of  the  two,  patient 
and  family,  should  be  identical,  but  whenever  a 
choice  must  be  made  between  them,  the  welfare 
of  the  community  has  the  right  of  way. 


The  Prevention  of  Tuberculosis    119 

This  is  why  effective  tuberculosis  work  must 
place  the  emphasis  on  the  control  of  the  last- 
stage  cases,  since  it  is  the  advanced  case  which  is 
of  most  danger  to  society.  For  example :  we  have 
two  families,  one  of  which  contains  a  moderately 
advanced  case,  whose  outlook  is  favourable,  while 
the  second  contains  a  last-stage  case  with  a  hope- 
less prognosis.  Both  patients  are  equally  intract- 
able; the  nurse  has  but  a  limited  time  at  her 
disposal,  and  must  choose  between  the  two,  since 
she  cannot  divide  her  days  equally  between  them. 
From  the  point  of  view  of  the  individual,  care  of 
the  earlier  case  would  better  repay  her  time  and 
effort ;  from  the  standpoint  of  the  greatest  good  to 
the  greatest  number,  she  must  concentrate  her 
efforts  on  the  advanced  case,  since  it  is  this  one 
which  is  immediately  dangerous.  The  earlier 
case  is  less  of  a  menace  to  those  about  him;  his 
obstinacy  and  refusal  to  follow  advice  mean  loss 
of  that  precious  time  in  which  life  and  death  are 
determined — but  if  he  chooses,  however  wilfully, 
to  waste  this  time,  it  is  his  own  loss  after  all.  It 
involves  no  one  else.  On  the  other  hand,  much 
more  is  involved  in  the  advanced  case.  Here  the 
patient's  death  is  inevitable,  but  it  can  be  kept 
from  occurring  amid  circumstances  which  would 
drag  down  others  with  him. 


i2o          The  Tuberculosis  Nurse 

In  the  majority  of  cases,  the  death  of  the  patient 
is  the  issue  to  be  expected,  however  much  it  may 
have  been  delayed  or  postponed- — a  result  sadden- 
ing and  discouraging  to  those  whose  previous 
training  has  been  to  preserve  life.  What  nurses 
are  not  trained  to  see,  and  what  many  of  them  have 
neither  imagination  nor  faith  enough  to  see,  is 
the  number  of  lives  that  are  probably  saved 
through  the  safeguarding  of  a  dying  individual. 
It  has  been  said  that  the  world  would  be  infinitely 
better  off  if  every  consumptive  in  it  could  die  to- 
day, since  by  this  loss  the  people  of  tomorrow 
would  be  saved.  The  nurse  must  cease  to  reckon 
in  terms  of  hundreds  of  patients — she  must  reckon 
in  terms  of  the  thousands  who  come  in  contact 
with  these  patients.  The  amount  that  can  be 
done  to  protect  these  thousands  is  the  standard 
by  which  the  work  must  be  judged  a  failure  or  a 
success.  If  she  bears  this  constantly  in  mind,  she 
will  not  become  so  easily  discouraged. 

Therefore,  to  sum  up  once  more:  upon  entering 
the  home,  the  nurse's  first  care  is  the  family,  and 
her  second  is  the  patient  himself.  But  it  is  by 
working  through  the  latter  that  the  former  may 
be  reached.  The  patient  himself  is  the  point  of 
attack,  and  if  in  the  ensuing  pages  he  becomes 
so  prominent  as  to  delude  one  into  thinking  that 


Calls  121 

his  welfare  alone  is  the  final  goal,  he  is  only  made 
prominent  in  order  that  we  may  reach  our  goal 
more  quickly. 

Sources  through  Which  Calls  are  Received. 
The  nurse  goes  to  the  patient's  home,  in  the  first 
instance,  at  the  request  of  some  one  who  has  sent 
her.  This  may  be  a  physician,  a  dispensary,  a 
neighbour,  or  she  may  even  go  on  her  own  shrewd 
suspicion  that  some  one  is  ill.  When  the  door  is 
opened  to  her  knock,  she  must  be  careful  how  she 
explains  her  coming.  If  a  municipal  nurse,  she 
should  never  say  that  she  has  come  from  the 
Health  Department,  for  this  conveys  a  suggestion 
of  authority  which  is  often  most  alarming.  Since 
the  patient  has  been  referred  to  the  Health 
Department  from  one  of  the  sources  just  men- 
tioned, it  would  be  more  tactful  to  name  the 
agency  through  which  the  call  was  received. 

When  calls  are  anonymous,  such  as  by  letter  or 
telephone  message,  or  when  the  sender  gives  his 
name  but  asks  that  it  be  withheld  from  the  patient, 
the  task  of  gaining  an  entrance  is  often  one  of 
considerable  difficulty,  and  requires  much  strategy. 
Calls  of  this  sort  should  never  be  refused,  since  in 
this  way  many  advanced  cases  are  brought  to 
light.  It  is  also  a  wholesome  indication  that  the 
community  is  learning  to  take  an  intelligent 


122          The  Tuberculosis  Nurse 

interest  in  an  infectious  disease,  whose  presence 
is  recognized  as  a  menace.  These  cases  can  best 
be  managed  if  the  nurse  assumes  the  responsibility 
herself,  saying  that  in  a  roundabout  way  she  has 
heard  that  there  is  illness  in  the  house,  and  so  has 
called  to  offer  her  services.  As  a  rule,  her  offer 
will  be  readily  accepted,  for  a  case  reported  in  this 
manner  is  usually  advanced,  and,  as  we  have  said 
before,  when  the  neighbours  diagnose  tuberculosis, 
they  are  frequently  right. 

Entering  the  Home.  As  a  rule,  when  a  nurse 
presents  herself  at  a  house  and  explains  her  errand, 
the  door  is  opened  wide  and  she  is  cordially  asked 
in.  In  some  instances,  it  is  held  half-shut,  in  a 
dubious  manner,  and  she  is  admitted  with  reluct- 
ance. Sometimes  it  is  banged  in  her  face.  It  is  a 
great  satisfaction  to  gain  an  entrance  into  homes 
of  the  latter  class;  to  win  the  confidence  of  such 
patients  is  a  victory  worth  having.  The  surest 
formula  for  entering  all  homes  is  a  broad  smile; 
to  stand  on  the  doorsteps  and  grin  like  a  Cheshire 
cat  disarms  suspicion,  and  once  across  the  thresh- 
old, the  victory  is  won. 

Taking  the  Patient's  History.  The  facts  con- 
cerning the  patient  must  be  gathered  in  his  home, 
and  they  are  of  two  kinds,  those  concerning  his 
physical  and  those  concerning  his  social  condition. 


Taking  the  Patient's  History      123 

The  first  thing  to  be  done  is  to  establish  a  feeling 
of  trust  between  the  patient  and  the  nurse.  As 
a  rule,  all  patients  are  communicative,  and  a  few 
adroit  questions  will  open  a  flood-gate  of  confidence 
from  which  can  be  gathered  full  details  concerning 
their  personal  and  family  affairs.  This  gives  the 
nurse  much  of  the  information  which  she  needs 
not  only  for  her  charts  and  records,  but  also  in 
order  to  deal  intelligently  with  each  case.  For 
unless  she  understands  the  patient,  and  knows 
something  of  his  social  and  economic  condition, 
she  will  not  be  able  to  give  helpful  advice.  But 
the  nurse  must  also  bear  in  mind  that  tuberculous 
persons  are  frequently  shy  and  sensitive,  and  it 
may  be  difficult  to  obtain  their  true  histories. 
They  may  be  more  ready  to  describe  their  physical 
symptoms  than  their  social  condition,  and  facts 
about  their  employment,  hours,  wages,  life  insur- 
ance, and  so  forth  are  not  always  forthcoming.  It 
is  inadvisable  to  make  notes  in  the  presence  of  the 
patient,  for  among  the  poorer  classes  there  is  a 
fear  that  their  words,  when  noted  in  a  book,  may 
in  some  mysterious  manner  be  used  against  them. 
Occasionally,  in  a  matter  of  some  importance, 
distrust  may  be  quieted  by  asking,  "May  I  just 
write  that  down?  The  doctor  will  be  interested 
in  that  and  I  want  to  get  it  right,"  but  it  is  well  to 


124         The  Tuberculosis  Nurse 

remember  that  suspicions  once  aroused  are  difficult 
to  quiet,  and  that  for  the  welfare  of  the  community 
it  is  better  to  teach  them  to  use  their  sputum  cups, 
than  to  antagonize  them  by  too  many  questions. 
The  nurse  should  get  all  the  facts  the  chart  calls 
for,  but  with  certain  patients  this  may  take 
considerable  time.  At  each  succeeding  visit  she 
can  ask  another  question  and  a  more  intimate  one, 
until  she  collects,  little  by  little,  all  the  data  she 
requires.  But  it  is  a  mistake  to  keep  on 
asking  questions — collecting  statistics — at  the 
expense  of  confidence  and  good- will. 

It  is  true  that  when  a  patient  goes  to  a  dispen- 
sary, he  is  prepared  to  answer  many  questions,  but 
there  is  this  difference — it  is  he  who  seeks  the 
dispensary.  When  the  tables  are  reversed,  when 
he  is  not  the  seeker  but  the  one  sought,  he  must  be 
handled  carefully.  There  are  of  course  many 
patients  to  whom  this  does  not  apply,  and  who 
willingly  volunteer  every  detail  of  their  lives,  but 
these  are  not  the  majority.  The  others,  the  more 
sensitive  ones,  make  up  three  quarters  of  the 
visiting  list.  The  antagonizing  of  a  patient  by 
tactless  questioning  is  an  unfavourable  commen- 
tary on  the  method  of  handling  him. 

Telling  the  Truth  to  the  Patient.  The  most 
difficult  of  the  nurse's  duties,  and  the  saddest,  is 


Telling  the  Truth  to  the  Patient    125 

to  tell  the  patient  the  nature  of  his  disease.  Yet 
this  must  be  done,  for  unless  he  knows  from  the 
very  beginning,  it  is  impossible  to  exact  from  him 
that  intelligent  co-operation  upon  which  rests  his 
sole  hope.  Only  on  the  rarest  occasions  is  there 
any  justification  for  withholding  this  knowledge. 
If  a  patient  has  but  a  few  more  days  to  live,  or  if 
a  hopeless  case  is  surrounded  by  scrupulous  care 
and  attention,  this  information  may,  if  it  seems 
best,  be  withheld.  But  these  are  exceptional 
instances.  To  hide  the  truth  from  an  early  or 
moderately  advanced  case  would  be  criminal. 
Apart  from  the  first  shock,  people  are  never  really 
injured  by  being  told  the  truth,  and  we  all  know 
of  hundreds  of  cases  in  which  lives  have  been 
ruthlessly  sacrificed  through  the  policy  of  silence. 
The  truth  need  not  necessarily  be  brutal — it  can 
be  made  full  of  hope,  interest,  and  encouragement. 
In  her  efforts  to  encourage  the  patient,  however, 
the  nurse  must  be  exceedingly  careful  never  to 
use  the  word  "cure."  Tuberculosis  is  never 
cured  in  the  sense  that  typhoid  fever  is  cured,  for 
example.  At  best,  it  is  only  arrested — that  is, 
brought  to  a  standstill,  to  a  point  where  the 
destruction  of  the  lung  tissue  goes  no  farther. 
Thus,  if  a  person  loses  one  or  two  fingers  from 
a  hand,  a  cure  would  imply  that  these  lost  fingers 


126         The  Tuberculosis  Nurse 

could  be  made  to  grow  again.  The  lung  tissue 
destroyed  by  tuberculosis  can  not  be  replaced  or 
renewed  any  more  than  lost  fingers  can  be  re- 
newed. Yet  a  lung,  in  spite  of  this  loss,  is  still 
able  to  serve  its  owner  well  and  enable  him  to  lead 
a  useful  and  happy  life,  just  as  a  hand  which  has 
lost  a  finger  or  two  may  still  be  a  fairly  useful  hand, 
and  serve  its  owner  well.  This  distinction  be- 
tween arrest  and  cure  must  be  made  perfectly  clear 
to  the  patient,  and  he  must  also  be  taught  that 
whether  the  arrest  of  the  disease  is  temporary  or 
permanent  depends  in  large  measure  upon  him- 
self. His  improvement  depends  upon  his  thor- 
ough understanding  of  his  illness,  and  upon  his 
ability  or  willingness  to  co-operate  as  to  treatment. 
According  to  Dr.  Minor,1  it  is  not  so  much  what 
a  patient  has  in  his  lungs,  as  what  he  has  in  his 
head;  namely,  common-sense,  which  determines 
his  recovery.  Therefore  to  keep  a  patient  in  the 
dark  concerning  his  condition,  and  yet  expect 
him,  without  knowing  the  reason,  to  do  over  and 
over  again  the  tiresome  routine  things  necessary 
to  improvement,  is  to  expect  the  impossible. 

In  making  the  best  of  things,  the  nurse  must 
never  over-encourage  the  patient.  A  half- 
starved,  overworked  person,  suddenly  put  on  a 

1  Dr.  Charles  L.  Minor,  Asheville,  North  Carolina. 


Truth  for  the  Family  127 

regime  of  fresh  air,  rest,  and  abundant  food,  will 
often  make  surprising  advances — up  to  a  certain 
point.  This  improvement  may  be  so  marked  that 
it  will  raise  false  hopes  of  its  continuance  and  the 
nurse  must  never  jeopardize  her  reputation  and  the 
confidence  imposed  in  her,  by  extravagant  state- 
ments as  to  what  may  be  accomplished.  The  over- 
confident patient  mistakes  temporary  improvement 
for  permanent  cure.  Tuberculosis  is  like  a  con- 
cealed enemy,  crouched  and  ready  to  spring  the 
moment  one  turns  one's  back,  and  it  requires 
constant  vigilance  to  guard  against  it.  If  this 
fact  could  be  securely  drilled  into  the  patients, 
there  would  probably  be  fewer  relapses. 

Truth  for  the  Family.  If  now  and  then  an 
exception  may  be  made  in  informing  the  patient 
of  his  condition,  there  are  no  conceivable  cir- 
cumstances under  which  this  knowledge  should 
be  withheld  from  his  family.  The  significance 
and  danger  of  tuberculosis  must  be  fully  explained 
to  all  who  are  exposed  to  it.  It  is  the  "family" 
who  constitute  public  opinion  as  far  as  the  patient 
is  concerned,  and  we  must  depend  upon  it  to  keep 
the  patient  up  to  the  standard  of  living  which 
means  his  improvement  and  their  protection. 
The  nurse  should  fully  explain  the  situation  to 
some  older,  responsible  member  of  the  household. 


128          The  Tuberculosis  Nurse 

This  can  best  be  done  out  of  the  patient 's 
presence.  She  must  speak  very  plainly,  using 
words  within  the  comprehension  of  her  hearers, 
so  that  they  cannot  fail  to  grasp  her  meaning. 
The  patient  needs  this  knowledge  in  order  to  get 
better — the  family  need  it  in  order  to  protect 
themselves.  It  is  a  sad  fact,  but  a  frank  appeal 
to  the  selfish  instinct  is  usually  productive  of 
better  results  than  one  made  upon  higher  grounds. 
Both  points  should  always  be  made,  but  the 
instinct  of  self-preservation  may  be  aroused  with 
less  prodding  than  is  needed  to  awaken  rudimen- 
tary altruism. 

Disposal  of  Sputum.  The  nurse  has  by  this 
time  prepared  the  way  for  the  prophylactic  sup- 
plies, which  she  carries  in  her  bag.  These  consist 
of  a  tin  cup,  fillers,  paper  napkins,  disinfectant, 
and  so  forth.  She  must  teach  the  patient  how 
to  use  and  dispose  of  them,  as  well  as  their  advan- 
tages— the  latter  reason  not  being  always  apparent 
to  the  ambulatory  case.  She  must  teach  that 
danger  to  himself  and  others  lies  in  the  sputum 
coughed  up  from  his  sick  lungs,  and  that  the 
simplest  way  to  receive  it  is  in  the  little  tin  cup, 
whose  waterproof  filler  can  easily  be  burned.  To 
the  advanced  case,  with  profuse  expectoration, 
these  light,  convenient  little  cups  are  a  great 


Disposal  of  Sputum  129 

improvement  over  the  household  spittoon,  which 
should  be  banished  at  once.  Bed  patients,  or 
those  too  weak  to  raise  even  this  light  cup  to  their 
lips,  may  be  taught  to  expectorate  into  the  paper 
napkins,  of  which  they  should  be  given  a  large 
supply.  A  simple  way  of  disposing  of  these 
napkins  is  to  pin  to  the  bedclothes  a  large  paper 
bag  (such  as  are  used  for  groceries),  into  which 
they  may  be  thrown.  Failing  a  paper  bag,  a 
cornucopia  made  of  newspaper  will  answer  the 
purpose,  the  object  being  to  let  the  patient  himself 
place  this  infective  material  in  a  receptacle  which 
can  be  burned  in  its  entirety,  without  its  contents 
being  handled  by  anyone  else. 

The  problem  of  destroying  sputum  cups  and 
their  contents  is  often  difficult.  The  proper  and 
only  sure  way  is  to  burn  them,  and  no  other  course 
should  be  considered.  Yet  in  summer,  when 
many  patients  have  no  coal  fires,  but  merely  gas 
or  oil  stoves,  many  difficulties  arise.  Under  such 
circumstances  the  patient  may  wrap  his  cup  in  a 
newspaper,  place  it  in  a  galvanized  iron  bucket, 
and  then  set  it  on  fire.  This  is  a  nuisance,  as  well 
as  somewhat  dangerous,  and  since  these  fillers 
and  their  contents  are  hard  to  burn,  the  simpler 
method  of  throwing  them  in  the  gutter  becomes 
an  irresistible  temptation.  To  see  that  these 


130         The  Tuberculosis  Nurse 

fillers  are  properly  destroyed  requires  constant 
supervision  and  instruction  and  is  one  of  the  most 
important  of  the  nurse's  duties. 

The  patient  should  destroy  the  fillers  himself — 
they  should  be  handled  by  no  other  member  of 
the  family,  unless  of  course  he  is  too  weak  and  ill 
to  do  it.  Even  when  very  ill,  however,  it  is 
nearly  always  possible  for  him  to  remove  the 
filler  from  the  cup  and  place  it  in  a  newspaper, 
which  is  then  rolled  up  by  someone  else  and 
carried  out  to  the  fire.  Needless  to  say,  the 
nurse  must  teach  those  who  touch  or  handle  this 
cup  how  important  it  is  to  wash  their  hands 
thoroughly  afterwards. 

Danger  of  Expired  Air.  After  giving  him  the 
tin  cup  and  fillers,  the  nurse  must  then  give  the 
patient  a  supply  of  paper  napkins,  and  explain 
their  purpose.  These  are  primarily  intended  to 
hold  over  the  mouth  when  coughing.  The  nurse 
must  explain  that  bacilli  are  liberated  in  great 
numbers  during  these  coughing  attacks,  and  that 
it  is  harmful  to  live  in  a  room  filled  with  these 
invisible  organisms.  Most  patients,  knowing 
themselves  to  be  infected,  are  indifferent  to  the 
welfare  of  those  about  them.  Therefore,  in  trying 
to  make  him  careful,  the  nurse  will  have  to  appeal 
to  his  selfish  instincts,  and  show  that  what  is  bad 


Isolation  of  Dishes  131 

for  other  people  is  equally  bad  for  him,  and  so 
diminishes  his  chances  of  improvement. 

It  is  comparatively  easy  to  instruct  a  patient  in 
the  use  of  his  sputum  cup,  but  to  obtain  any  sort 
of  carefulness  in  this  equally  grave  matter — liber- 
ation of  bacilli  in  the  expired  air — is  well-nigh 
impossible.  This  is  partly  due  to  the  nature  of 
the  disease — in  its  most  infectious  stages,  the 
patient  is  so  racked  with  paroxysms  of  coughing, 
that  it  is  impossible  for  him  to  keep  his  mouth 
covered,  or  to  think  of  anything  except  his  own 
sufferings. 

On  the  street,  these  paper  napkins  may  be  used 
to  spit  into,  the  patient  carrying  them  home  again 
in  the  waterproof  pocket  pinned  inside  his  coat. 
Fine  details  of  this  sort  are  difficult  to  insist  upon, 
however — the  convenience  of  the  street  and  of 
the  gutter  making  a  stronger  appeal  than  any 
newly  acquired  aesthetic  valuations.  This  is  of 
minor  importance,  however;  the  real  danger  lies 
in  the  home. 

Isolation  of  Dishes.  The  consumptive  should 
have  special  dishes  provided  for  him,  which  should 
never  be  used  by  any  other  member  of  the  house- 
hold. If  the  family  can  afford  it,  they  should  buy 
dishes  of  a  special  pattern,  unlike  those  in  general 
use,  since  in  this  way  the  chances  of  mixing  them 


132          The  Tuberculosis  Nurse 

are  greatly  lessened.  Otherwise,  constant  care 
must  be  taken  to  keep  them  apart.  The  patient's 
dishes  should  stand  on  their  own  corner  of  the 
shelf,  be  washed  in  a  separate  dishpan,  and  dried 
with  a  special  towel.  Once  a  week,  for  general 
cleanliness'  sake,  they  should  be  boiled.  Any  dish 
which  may  have  got  mixed  with  them,  or  has 
inadvertently  been  used  by  the  patient,  should  be 
boiled  before  being  used  again  in  the  household. 
The  patient  need  not  necessarily  know  that  his 
dishes  are  isolated,  since  details  of  this  kind  are 
explained  to  the  family  rather  than  to  the  sick 
man. 

If  he  is  a  bed  patient,  it  is  an  easy  matter  to 
isolate  his  dishes,  without  his  knowledge ;  when  he 
is  up  and  about,  it  is  much  harder.  Patients  are 
particularly  sensitive  about  this,  and  some  fami- 
lies, rather  than  risk  hurting  the  feelings  of  the 
invalid,  prefer  to  boil  the  dishes  after  every  meal. 
This  adds  so  much  to  the  work  of  the  busy  house- 
hold that  after  a  time  all  attempts  at  isolation  are 
dropped.  This  matter  calls  for  considerable 
vigilance  on  the  part  of  the  nurse. 

Linen,  Household  and  Personal.  All  linen, 
including  clothing  and  bed  linen  that  has  been 
used  by  the  patient,  should  be  boiled  before  it  is 
washed.  There  seems  to  be  some  prejudice 


Disinfectant  and  Other  Supplies    133 

against  this  previous  boiling,  as  the  family  are  apt 
to  maintain  that  it  makes  it  more  difficult  to  get 
the  linen  clean  afterward.  The  nurse  should  over- 
come their  objections,  and  emphasize  the  necessity 
for  the  utmost  caution  in  regard  to  this  infective 
material. 

Disinfectant  and  Other  Supplies.  At  a  later 
visit,  the  disinfectant  may  be  given,  as  well  as  the 
waterproof  pockets  and  books  of  information. 
During  the  first  visit,  it  is  better  to  give  only  the 
most  important  of  the  supplies — the  tin  cup, 
fillers,  and  napkins — and  to  save  the  rest  for 
another  time.  For  on  her  first  visit  the  nurse  is  a 
stranger — later,  she  becomes  a  friend.  Therefore 
she  will  make  better  headway  if  on  her  first  appear- 
ance she  does  not  burden  the  family  with  too  much 
instruction  and  too  much  detail.  It  is  better  to  say 
too  little  than  too  much,  better  to  leave  something 
unsaid  until  the  next  time,  rather  than  overwhelm 
those  she  visits  with  a  mass  of  advice  which  they 
cannot  assimilate.  Her  first  visit  has  been  made 
as  the  bearer  of  distressing  news,  no  matter  how 
gently  and  carefully  it  may  have  been  broken, 
and  the  distress  and  confusion  which  often  arise 
fill  the  minds  of  her  hearers  to  the  exclusion  of 
nearly  everything  else. 

During  her  later  visits,   she  will  have  ample 


134          The  Tuberculosis  Nurse 

opportunity  to  say  all  that  should  be  said- — and  at 
each  succeeding  call  she  will  find  that  much  of 
what  she  said  the  time  before  has  been  forgotten, 
misapplied,  or  altogether  ignored.  Tuberculosis 
work  means  the  constant  and  incessant  repetition 
of  the  same  thing,  trying  by  every  device  imagin- 
able to  point  the  way,  to  make  an  impression,  to 
obtain  some  slight  degree  of  carefulness  which  may 
mean  the  protection  of  other  people. 

Phthisiphobia.  People  frequently  reproach  the 
nurse  with  the  fact  that  her  teaching  tends  to 
alarm  the  patient  and  his  family,  and  to  produce  a 
community  phthisiphobia  which  works  great  hard- 
ship in  individual  cases.  As  far  as  the  community 
is  concerned,  fear  of  tuberculosis  is  a  good,  whole- 
some sentiment,  and  infinitely  preferable  to  ignor- 
ance and  indifference.  We  cannot  have  too  much 
of  a  public  opinion  which  declines  to  be  exposed  to 
this  disease,  and  which  will  therefore  provide  the 
machinery  to  cope  with  it.  As  far  as  the  family 
is  concerned,  we  have  never  been  able  to  produce 
enough  fear  of  tuberculosis.  It  would  greatly 
facilitate  the  campaign  if  the  first  feeling  of  alarm 
and  apprehension  could  become  permanent,  in- 
stead of  very  transitory  and  fleeting.  Tubercu- 
losis is  so  slow  and  insidious  in  its  onset, — there 
is  nothing  spectacular,  by  which  we  can  demon- 


Phthisiphobia  135 

strate  to  the  ignorant  mind  the  relation  between 
cause  and  effect,  exposure  and  infection , — that 
the  educational  method  alone  is  inadequate  to  deal 
with  the  situation.  If  the  alarmed  patient  and 
his  household  could  or  would  continue  the  preven- 
tive measures  which  at  first  so  strongly  appeal  to 
them,  and  which  in  the  beginning  they  apply  with 
boundless  enthusiasm,  we  should  have  compara- 
tively little  difficulty.  But  the  disease  is  chronic 
and  slow ;  the  scare  wears  off,  and  the  cry  of  "Wolf, 
Wolf"  loses  its  value.  And  then  follows  a  relaxa- 
tion of  prophylactic  measures.  Each  time  the 
nurse  must  stir  them  up  anew — encourage, 
threaten,  alarm,  coax,  bribe, — do  everything  in 
her  power  to  awaken  them  from  their  mental 
apathy  and  drowsiness,  which,  as  in  morphia 
poisoning,  precedes  death. 


CHAPTER  XI 

Inspection  of  the  House — The  Patient's  Bedroom — Porches — 
Gardens  and  Tents — Flat  Roofs — Clothing  and  Bedclothing 
—Artificial  Heat— Rest— Fresh  Air— Food— Cooking— The 
Bedridden  Patient. 

Inspection  of  the  House.  On  her  first  visit 
the  nurse  must  inspect  every  room  in  the  patient's 
home,  with  a  view  to  knowing  what  possibilities 
it  affords  for  treatment  and  isolation.  Some 
contain  no  facilities  whatsoever;  some  but  meagre 
ones,  while  in  others  may  be  found  excellent 
opportunities  which  the  patient  must  be  taught  to 
use.  Before  advising  any  change  or  rearrange- 
ment, several  factors  must  be  considered:  the 
stage  of  the  disease,  number  in  family,  financial 
condition,  home  surroundings  and  the  institu- 
tional facilities  of  the  community.  The  course 
to  be  taken  depends  whether  or  not  there  is  a 
hospital,  or  whether  or  not  the  patient  must  wait 
some  time  before  admission.  The  first  object  is 
the  protection  of  the  family,  but  all  those  measures 
which  bring  this  about,  offer  at  the  same  time  the 
maximum  advantage  to  the  patient  himself.  To 

136 


The  Patient's  Bedroom  137 

remove  him  to  an  institution  is  the  best  way  to 
accomplish  both  ends.  If  this  cannot  be  done, 
the  nurse  must  endeavour  to  secure  conditions 
in  the  home  which  as  nearly  as  possible  approach 
those  of  an  institution.  The  closer  this  approxi- 
mation, the  greater  the  gain  to  both  patient  and 
those  who  surround  him. 

The  Patient's  Bedroom.  The  first  thing  to  be 
considered  is  the  patient's  bedroom,  or  sleeping 
quarters.  He  should  have  this  room  to  himself, 
sharing  it  with  no  one.  If  this  cannot  be  ar- 
ranged, he  should  at  least  have  a  bed  to  himself. 
This  bed,  and  that  of  the  other  person,  or  persons, 
should  be  placed  at  opposite  ends  of  the  room,  and 
as  far  apart  as  possible. 

The  more  windows  in  the  room  the  better ;  these 
should  be  kept  open  to  their  fullest  extent.  In 
some  houses,  where  the  windows  are  small,  it  is 
often  possible  to  lift  out  the  entire  sash,  thereby 
admitting  more  air.  The  bed  should  be  placed 
directly  at  the  window,  so  that  the  patient  may 
lay  his  pillow  on  the  window  sill  if  he  chooses. 
He  should  be  instructed  to  sleep  facing  the  open- 
ing, in  order  to  get  all  the  air  he  can.  The  nurse 
should  rearrange  the  furniture  as  she  wishes  it, 
otherwise  misunderstandings  may  occur.  If  the 
family  object  to  her  moving  it  but  promise  to  do 


138          The  Tuberculosis  Nurse 

this  themselves,  she  must  be  careful  to  inspect  the 
room  again  on  her  next  visit,  to  see  that  this  has 
been  properly  done.  Even  with  families  that  have 
been  under  supervision  a  long  time,  it  is  well  to 
inspect  the  bedrooms  occasionally,  for  the  patient's 
bed  always  has  a  tendency  to  retreat  into  a  remote 
corner  of  the  room,  especially  in  winter. 

The  floor  should  be  bare,  and  this,  together  with 
all  other  plane  surfaces  should  be  washed  several 
times  a  week  with  hot  water  and  soda.  Great 
caution  must  be  exercised  in  making  a  sanitary 
sick-room,  but,  in  her  enthusiasm  to  produce  ideal 
conditions,  the  nurse  must  remember  that  articles 
used  for  months  by  the  patient,  and  suddenly 
banished  from  his  proximity,  may  be  very  deadly 
elsewhere.  In  advising  that  carpets  and  curtains 
be  removed,  she  must  be  careful  what  becomes  of 
them.  If  germ-laden  carpets  are  sold,  or  given  to 
the  neighbour  next  door,  they  would  better  remain 
where  they  are.  Poor  people  find  it  hard  to  with- 
stand the  temptation  to  sell  or  give  away  service- 
able articles,  which  is  of  course  but  natural,  but  the 
nurse  must  be  on  guard  against  such  occurrences. 

To  have  an  ideal  sick-room,  there  is  no  necessity 
for  its  being  depressing  by  its  bleak  ugliness,  or 
bare  and  dismal  as  a  cell.  Washable  muslin 
curtains  may  be  permitted,  and  there  is  no  objec- 


The  Patient's  Bedroom  139 

tion  to  pictures  and  ornaments  in  moderation. 
It  is  bad  enough  to  have  tuberculosis,  without 
penalizing  the  patient  by  removing  from  him  all 
those  little  treasures  which  give  him  pleasure  and 
harm  no  one. 

In  selecting  a  good  room  for  the  patient,  the 
nurse  may  find  it  necessary  to  have  him  exchange 
with  some  other  member  of  the  household.  In 
this  event,  great  care  must  be  taken  that  the  room 
vacated  by  the  patient  is  thoroughly  cleaned  and 
disinfected  before  being  occupied  by  anyone  else. 
There  are  also  circumstances  which  render  it  un- 
wise to  make  this  exchange :  for  example,  say  that 
we  have  a  moderately  advanced  case,  whose 
improvement  is  doubtful.  He  is  occupying  a  room 
with  one  window — not  ideal,  but  fair  enough. 
There  is  also  another  room  in  the  house,  containing 
several  windows,  altogether  brighter  and  larger, 
but  occupied  by  three  or  four  people,  so  far 
healthy  and  sound.  To  exchange  rooms  under 
such  conditions  would  be  bad  policy — it  would 
be  of  little  advantage  to  the  patient  himself, 
while  the  other  people  would  be  subjected  to 
overcrowding  and  bad  ventilation,  which  would 
decidedly  lower  their  resistance.  Those  in  pro- 
longed, intimate  contact  with  a  consumptive  must 
not  be  allowed  to  reduce  their  vitality  in  any  way. 


140          The  Tuberculosis  Nurse 

To  arrange  a  good  sanitary  room  for  a  patient 
does  not  in  the  least  mean  that  he  will  use  it. 
Such  a  room  would  doubtless  appear  well  in  a 
photograph,  illustrating  the  "before  and  after" 
phases  of  the  nurse's  activity,  but  this  does  not 
necessarily  mean  that  the  patient  is  isolated  and 
harmless.  He  will  probably  use  his  nice  room 
for  sleeping  purposes  only,  and  it  is  what  he  does 
with  the  remainder  of  his  time  that  counts.  He 
comes  into  contact  with  the  household  at  meals, 
in  the  evenings,  and  on  innumerable  other  occa- 
sions, and  the  consciousness  of  an  immaculate 
bedroom  should  not  lessen  the  nurse's  anxiety 
about  the  kitchen,  the  living-room,  and  the  family 
sofa.  There  is  where  the  danger  lies. 

Porches.  In  some  houses  we  find  a  porch 
readily  available  for  the  patient's  use,  where  he 
can  sleep  and  spend  most  of  his  daylight  hours. 
It  is  sometimes  difficult  to  induce  him  to  make  use 
of  it,  however.  We  must  also  remember  that 
there  is  a  great  difference  in  porches.  Some  are 
narrow,  unroofed,  exposed  to  sun  and  wind,  have 
disagreeable  outlooks,  for  instance,  as  on  un- 
savoury alleys,  and  in  other  ways  are  unfit  to  be 
used  as  living-rooms.  They  should  be  used,  of 
course,  whenever  practicable,  since  undoubtedly 
the  patient  will  get  more  air,  and  more  constantly 


Gardens  and  Tents  141 

changing  air,  than  if  he  sleeps  indoors.  Yet  it  is 
well  to  realize  that  a  place  where  the  patient  is 
unsheltered,  uncomfortable,  and  where  he  cannot 
sleep  or  have  a  quiet  mind,  is  often  far  less  valu- 
able than  a  good  bedroom  which  may  give  him 
all  of  these  necessities. 

Patients  in  well-to-do  circumstances  can  equip 
their  porches  admirably,  both  with  awnings  and 
with  canvas  screens.  These  latter  should  roll  up 
from  the  floor,  rather  than  down  from  the  roof. 
Screens  and  awnings  can  be  made  to  order  by  any 
awning  or  sail  maker;  the  price  varies  with  their 
construction,  from  about  five  dollars  upward. 
To  teach  a  patient  to  use  a  porch  for  sleeping  and 
also  to  use  it  as  a  living-room  should  be  the  nurse's 
constant  endeavour.  Even  an  ideal  porch  is  like 
an  ideal  bedroom — only  valuable  if  it  is  used. 

Gardens  and  Tents.  Many  houses  have  little 
yards  or  gardens,  easily  adaptable  for  open-air 
living.  A  tent  may  be  erected  for  sleeping  pur- 
poses, if  the  space  is  large  enough  and  the  family 
can  afford  it.  Women  and  children  are  usually 
afraid  to  sleep  under  such  exposed  conditions,  and 
in  consequence  refuse  to  make  use  of  what  would 
otherwise  be  an  excellent  opportunity.  These 
gardens  may  be  used  during  the  day,  however, 
and  the  patient  made  comfortable  in  a  reclining 


142          The  Tuberculosis  Nurse 

chair  or  lounge.  But  excellent  as  they  appear 
theoretically,  the  extremes  of  our  climate,  exces- 
sive heat  and  cold,  often  make  them  unpractical 
for  the  consumptive's  use.  Under  such  circum- 
stances, these  little  back  yards  often  become  any- 
thing but  ideal  places  in  which  to  "take  the  cure." 

Flat  Roofs.  We  also  find  flat  roofs  or  sheds 
attached  to  certain  houses  in  the  tenement  dis- 
tricts. These  sometimes  offer  excellent  condi- 
tions for  long  hours  out-of-doors,  and  may  also  be 
used  as  sleeping-porches.  The  nurse  must  be 
alert  to  seize  all  opportunities  which  present 
themselves,  and  to  teach  her  patients  to  utilize 
them. 

Clothing  and  Bedclothing.  In  her  effort  to 
teach  her  patient  to  sleep  out-of-doors,  and  to 
spend  most  of  his  waking  time  there,  the  nurse 
must  remember  that  in  winter  this  is  impossible, 
if  he  is  insufficiently  clad.  The  vitality  of  the 
consumptive  is  always  below  par,  consequently 
he  needs  much  more  clothing  than  would  a  healthy 
person  under  the  same  conditions.  It  is  impossible 
to  expect  patients  to  remain  out-of-doors  if  they 
are  cold  and  uncomfortable,  and  before  insisting 
upon  open-air  treatment  the  nurse  must  see  that 
it  is  possible  for  them  to  take  it.  If  they  lack  the 
necessary  clothing' — underwear,  blankets,  sweaters, 


Rest  143 

overcoats — these  may  be  procured  through  some 
charitable  association.  It  is  a  part  of  the  nurse's 
duties  to  arrange  for  this  assistance,  the  question  of 
which  will  be  dealt  with  in  a  later  chapter. 

Artificial  Heat.  In  addition  to  extra  clothing, 
artificial  heat  is  nearly  always  necessary,  and  this 
may  be  procured  by  means  of  hot-water  bottles, 
hot  bricks,  stove  lids,  and  so  forth.  The  clothing 
itself  may  be  sufficiently  warm,  and  a  hot  brick 
may  be  all  that  is  necessary  to  keep  the  patient 
in  the  yard,  rather  than  in  the  kitchen.  The 
patient  must  learn  to  live  in  the  open  air — and 
the  family  must  also  learn  that  their  safety  lies  in 
keeping  him  there,  and  is  well  worth  the  trouble 
of  filling  a  hot- water  bottle  now  and  then.  A  hot 
kitchen  is  the  worst  place  in  the  world  for  a  cough- 
ing consumptive — and  a  coughing  consumptive  is 
the  worst  thing  in  the  world  for  a  hot  kitchen — • 
and  the  inhabitants  thereof.  It  is  fortunate  that 
the  rule  works  both  ways,  so  that  both  sides  may 
be  appealed  to. 

Rest.  The  three  things  necessary  to  improve- 
ment are  rest,  fresh  air,  and  food.  Not  one  alone, 
nor  two  alone,  but  all  three  together,  if  results 
are  to  be  obtained.  It  is  very  difficult  to  impress 
upon  the  patient  that  rest  is  not  exercise,  and 
that  nothing  is  as  bad  for  him  as  exertion.  He 


144         The  Tuberculosis  Nurse 

instinctively  associates  fresh  air  with  exercise, 
and  does  not  realize  that  fresh  air  and  rest  is  the 
combination  required.  If  a  physician  is  in  charge 
of  the  case,  he  of  course  would  direct  the  amount 
of  exercise  to  be  taken,  but  if,  as  often  happens, 
there  is  no  doctor  in  attendance,  the  nurse  must 
use  her  own  knowledge  of  what  is  best.  In  a 
sanatorium  the  usual  rule  is  that  all  patients  with 
more  than  99  degrees  of  fever  shall  stay  in  bed. 
After  a  hemorrhage,  absolute  rest  is  of  course 
indicated. 

Therefore  the  nurse  should  try  to  induce  her 
patients  to  rest  as  much  as  possible — not  to  walk 
about,  or  to  drag  themselves  to  a  park,  and  so 
tire  themselves  out.  Exertion  increases  fever, 
and  this  will  counteract  what  benefit  might  have 
been  gained  through  the  fresh  air.  They  should 
be  taught  to  sit  comfortably  in  their  gardens, 
on  their  front  sidewalks,  on  their  porches,  at  their 
open  windows.  Best  of  all,  they  should  go  up- 
stairs to  their  bedrooms,  and  lie  at  full  length  on 
the  bed  placed  next  to  the  open  window.  By 
thus  emphasizing  the  importance  of  rest — synony- 
mous in  this  case  with  outdoor  rest — the  nurse  is 
not  only  giving  sound  advice  to  her  patient,  but 
she  is  protecting  the  community  from  the  ambula- 
tory consumptive. 


Fresh  Air  145 

Whenever  possible,  the  patient  should  be  in- 
duced to  remain  in  bed  permanently.  The 
sooner  the  weary,  advanced  case  gives  up  his 
painful  wanderings,  stops  dragging  himself  from 
his  own  to  his  neighbour's  kitchen,  or  to  the 
hospitable  bar,  the  better  for  him  and  for  the 
community.  If  he  were  to  go  to  bed  in  a  hospital, 
instead  of  at  home,  greater  still  would  be  the  gain. 
The  part  of  the  community  constituted  by  his 
family  would  be  freed  from  danger,  while  he  him- 
self would  be  adequately  cared  for.  Again  we  are 
struck  by  the  coincidence  of  what  is  best  for  the 
patient  being  also  best  for  those  who  surround  him. 

Fresh  Air.  Fresh  air  is  the  second  great  essen- 
tial in  the  treatment  of  tuberculosis,  and  every 
patient  should  be  taught  to  spend  as  many  hours 
as  possible  out-of-doors.  The  nurse  must  ex- 
plain in  words  of  one  syllable  why  this  is  nec- 
essary— that  clean,  pure  air  contains  life-giving 
oxygen,  and  that  to  breathe  it  entails  little  ex- 
ertion on  the  part  of  the  sick  lungs.  On  the 
other  hand,  impure  air  contains  no  upbuilding 
principle,  but  greatly  taxes  the  lungs  and  makes 
breathing  difficult.  Outdoors,  every  breath  of 
air  is  clean  and  pure ;  indoors,  especially  in  a  closed 
room,  one  is  soon  reduced  to  rebreathing  expired 
air,  with  all  its  impurities.  Just  as  tainted  meat  or 


146          The  Tuberculosis  Nurse 

spoiled  fruit  or  vegetables  are  unwholesome,  and 
bad  for  the  stomach  and  general  system,  so  is 
impure  air  harmful  to  the  lungs  and  general 
health.  One  organ  surely  deserves  as  much  con- 
sideration as  another.  And  when  the  lungs 
become  impaired  through  disease,  it  is  still  more 
necessary  to  take  care  of  them.  They  need  to  be 
strengthened  in  every  way,  in  order  to  defy  the 
inroads  of  tuberculosis.  The  nurse  must  make  her 
points  clear  and  emphatic;  if  the  patient  takes  an 
intelligent  interest  in  his  treatment,  it  will  become 
less  irksome. 

But  it  is  not  enough  to  tell  the  patient  why  he 
needs  fresh  air — the  nurse  must  show  him  how  to 
get  it.  He  is  singularly  helpless  and  unable  to 
recognize  such  ways  for  himself.  Also  she  must 
overcome  his  objections  and  bring  him  to  her  way 
of  thinking.  Thus,  he  objects  to  his  porch  be- 
cause it  is  shaky,  or  because  it  may  only  be  reached 
by  passing  through  another  person's  room.  In- 
vestigation may  prove  the  shakiness  imaginary, 
or  at  least  not  dangerous,  while  the  other  person 
may  be  only  too  willing  to  let  his  room  be  used  as 
passageway  to  this  desirable  goal.  Again,  he 
objects  to  sitting  in  the  yard,  or  on  the  sidewalk, 
or  even  at  his  window,  for  fear  of  what  the  neigh- 
bours may  say.  It  should  be  pointed  out  that  his 


Food  147 

health  is  more  important  than  their  comments — 
whatever  they  may  or  may  not  be — and  that  his 
interest,  not  theirs,  should  come  first.  The  nurse 
must  plan  every  little  detail;  she  must  select  his 
chair  or  sofa;  must  show  how  he  can  be  warmly 
tucked  up,  and  sit  out  of  the  wind  or  sun,  as  the 
case  may  be.  She  must  teach  the  family  about  the 
hot  brick  and  how  to  place  it  at  the  patient's  feet— 
or  two  hot  bricks,  if  need  be.  It  is  not  enough  to 
say:  Do  thus  and  so — she  must  herself  demon- 
strate how  the  thing  is  done.  The  consumptive  is 
sick  and  helpless  and  needs  constant  reassuring. 
If  he  belongs  to  the  very  poor,  he  has  little  to  do 
with,  and  is  so  ignorant  that  he  cannot  make  the 
most  of  what  he  has.  This  teaching  is  one  of  the 
chief  duties  of  the  nurse. 

'  Food.  The  third  great  essential  in  the  trilogy 
is  food.  The  patient's  diet  is  of  the  utmost 
importance,  since  his  ability  to  take  and  assimi- 
late nourishing  food  determines  his  ability  to 
build  up  enough  resistance  to  cope  with  tuberculo- 
sis. Generally  speaking,  he  should  be  encouraged 
to  eat  every  kind  of  nourishing  food  that  he  can 
digest — for  tuberculosis  does  not  call  for  a  special 
diet  as  does  typhoid  or  diabetes.  Anything 
which  specifically  disagrees  with  him  should,  of 
course,  be  excluded.  The  question  of  food  values 


148          The  Tuberculosis  Nurse 

must  be  considered;  with  the  poor,  this  requires 
careful  teaching  and  explanation.  The  nurse 
should  point  out  the  difference  between  food  which 
merely  fills  the  stomach,  and  food  which  nourishes 
and  upbuilds.  In  the  first  class  may  be  instanced 
cabbage,  turnips,  doughnuts,  pies — all  highly 
esteemed  by  the  poor,  and  cheap  and  indigestible. 
In  the  second  class  are  meat,  eggs,  milk,  fish,  rice, 
beans,  hominy,  oatmeal,  and  so  forth.  Some  of 
these  nourishing  foods — rice,  beans,  hominy,  oat- 
meal— are  no  more  expensive  than  cabbage  and 
pie.  The  family  should  be  taught  the  difference. 
Very  harmful  and  indigestible  are  the  products 
of  the  corner  bakery,  the  penny  candies,  the 
enormous  pickles,  and  the  copious  strong  brews 
of  tea  and  coffee  which  form  so  large  a  part  of  the 
dietary  of  those  near  the  poverty  line.  Consider- 
able money  is  spent  on  these  things — often  money 
enough  to  provide  a  wholesome  meal,  if  the 
family  but  knew  how  to  discriminate.  In  plan- 
ning a  patient's  diet,  the  nurse  will  have  to  do  as 
much  exclusive  as  inclusive  propaganda. 

It  is  not  necessary  to  insist  on  milk  and  eggs, 
certainly  not  in  the  abnormal  quantities  which  a 
few  years  ago  were  considered  indispensable  in 
the  treatment  of  tuberculosis.  If  a  patient  likes 
these  and  can  afford  them,  well  and  good,  but  they 


Food  149 

need  by  no  means  be  made  the  staple  article  of 
diet.  This  rich  and  highly  concentrated  food  has 
a  tendency  to  cause  indigestion,  and  since  this  is 
one  of  the  gravest  and  most  distressing  complica- 
tions of  tuberculosis,  it  must  be  prevented  at  all 
costs.  A  patient  unable  to  digest  his  food  has  but 
slim  chance  of  increasing  his  vitality,  and  little  hope 
of  improvement.  Therefore,  in  advising  raw  eggs, 
the  nurse  must  be  very  careful ;  one  or  two  a  day 
will  be  sufficient,  over  and  above  the  regular  meals. 

Milk  should  be  substituted  for  tea  and  coffee. 
Three  or  four  glasses  a  day  will  be  enough,  and 
even  that  may  be  too  much  if  the  patient  eats  well 
of  other  things.  In  place  of  raw  milk,  it  may  be 
peptonized,  malted,  given  hot,  made  into  junket, 
taken  in  cocoa,  or  as  one  of  the  flavoured  milk- 
shakes, or  turned  into  clabber  or  buttermilk. 
These  varieties  of  milk  are  good  for  advanced 
patients,  who  may  also  be  given  egg  albumen, 
flavoured  with  lemon,  orange,  ginger  ale,  grape 
juice,  and  so  forth.  The  family  must  be  taught  to 
make  these  little  innovations,  in  the  ordinary  diet, 
and  instruction  in  these  is  part  of  the  nurse's  work. 

By  careful  supervision  and  attention,  the  nurse 
can  procure  a  very  satisfactory  dietary,  one  both 
nourishing  and  digestible.  Three  good  meals  a 
day,  with  a  little  nourishment  between  meals  and 


150          The  Tuberculosis  Nurse 

at  bedtime  (a  glass  of  milk  or  its  equivalent), 
will  be  found  quite  satisfactory.  If  a  doctor  is  in 
attendance,  he  will  of  course  arrange  such  diet  as 
he  thinks  best,  but  if  the  nurse  is  left  to  herself, 
she  will  not  overstep  the  boundaries  if  she  advises 
some  such  plan  as  we  have  outlined. 

As  we  have  said,  indigestion  is  one  of  the  most 
frequent  complications  of  tuberculosis.  In  some 
cases  this  can  be  overcome  or  relieved  by  advising 
rest  in  the  reclining  position  for  an  hour  before, 
and  immediately  following  meals.  If  the  patient 
lies  flat  on  the  bed  or  lounge,  this  will  be  more 
effective  that  if  he  sits  in  a  rocking-chair. 

Cooking.  Cooking  and  the  preparation  of  food 
also  require  supervision,  for,  especially  among  the 
poor,  dense  ignorance  of  these  important  matters 
prevails.  Through  improper  cooking,  wholesome, 
excellent  food  is  often  turned  into  something 
quite  the  reverse,  indigestible  and  injurious  to 
a  high  degree;  or,  if  not  ruined,  it  may  lose  so 
much  of  its  food  value  as  to  be  practically  worth- 
less. Thus,  a  hard-boiled  egg  or  a  fried  egg  (es- 
pecially if  fried  on  both  sides)  is  less  easy  to  digest 
than  a  soft-boiled  one.  A  good  piece  of  meat 
may  have  its  entire  value  removed  by  overcook- 
ing. All  nurses  have  had  training  in  dietetics, 
and  this  special  knowledge  is  of  immense  value  in 


The  Bedridden  Patient  151 

public  health  work,  where  for  the  most  part  they 
come  in  contact  with  a  class  of  people  whose 
ignorance  of  culinary  matters  is  profound. 

Alcohol.  The  question  of  giving  alcohol  fre- 
quently arises  in  this  work.  If  a  doctor  is  in 
attendance,  he  will  prescribe  it  or  not  as  he  chooses. 
But  if  the  nurse  alone  is  in  charge  of  the  case,  and 
the  matter  is  left  to  her  decision,  we  feel  that  the 
ruling  of  the  Phipps  Dispensary  of  the  Johns 
Hopkins  Hospital  is  a  wise  one  to  follow — no 
alcohol  for  the  consumptive  under  any  circum- 
stances. This  means  that  there  shall  be  no  egg- 
nogs,  made  with  brandy,  sherry,  rum,  etc.;  no 
sherry  with  raw  eggs — no  indulgence  in  wine,  beer, 
or  alcoholic  stimulants  of  any  sort. 

The  Bedridden  Patient.  When  the  patient  is 
confined  to  bed,  the  nurse's  task  becomes  easier. 
Isolation,  therefore  better  protection  to  the 
family,  is  more  readily  secured  than  when  he 
wanders  from  room  to  room,  leaving  a  trail  of 
germs  behind  him.  It  is  well  to  exclude  from  the 
sick-room  every  one  except  those  in  actual  attend- 
ance upon  the  patient ;  this  is  especially  necessary 
in  the  case  of  children,  to  whom  the  danger  is 
greatest.  Neighbours  and  friends  should  also  be 
excluded,  and  if  they  refuse  to  consider  the  risk, 
the  plea  for  exclusion  should  be  made  on  the 


152          The  Tuberculosis  Nurse 

ground  that  visitors  are  disturbing  and  harmful 
to  the  patient. 

In  the  sick-room  we  sometimes  find  the  young 
children  of  neighbours,  whose  mothers  are  all  un- 
conscious of  the  danger  to  which  they  are  exposed. 
If  through  sheer  indifference,  the  patient's  family 
does  not  exclude  these  children,  it  would  then 
become  the  nurse's  duty  to  seek  out  their  parents 
and  warn  them.  When  a  patient's  household 
becomes  indifferent  to  community  welfare,  the 
nurse  should  then  extend  her  teachings  farther 
afield — into  the  next  house  or  block  if  need  be — • 
and  try  to  protect  others  who  are  unknowingly 
exposed  to  infection. 

In  brief,  these  are  the  duties  of  the  nurse  in  the 
home  of  the  patient.  At  her  first  visit,  she  cannot 
say  everything  she  wishes,  but  later  it  will  be 
possible  to  do  so.  In  many  cases,  the  household 
will  be  suspicious,  antagonistic,  or  not  inclined  to 
want  her,  so  that  she  must  feel  her  way  cautiously, 
step  by  step.  It  may  take  two,  three,  four,  or 
even  a  dozen  visits  to  accomplish  her  object, 
and  before  she  can  drive  her  points  home  with  the 
requisite  vigour.  When  the  situation  is  acute, 
and  the  danger  great,  it  is  difficult  and  discourag- 
ing to  make  haste  slowly,  yet  this  policy  will  pay 
in  the  end.  It  is  better  to  proceed  cautiously 


The  Bedridden  Patient  153 

with  an  uneasy  family,  winning  them  gradually 
from  point  to  point,  than  to  arouse  their  resent- 
ment by  an  impatient  enthusiasm  which  sees  no 
wisdom  in  delay. 

In  dealing  with  patients,  the  nurse  must  speak 
plainly ;  it  will  not  do  to  insinuate  or  imply.  What 
she  has  to  say  must  be  said  straightforwardly,  in 
simple  words  adapted  to  the  intelligence  of  her 
hearers.  The  situations  one  encounters  in  this 
work  are  often  sad  and  trying  to  a  degree,  and  it 
would  be  far  easier  to  insinuate  a  disagreeable 
or  painful  thing  than  to  speak  out  plainly.  The 
nurse  who  cannot  express  herself  clearly,  forcibly, 
and  convincingly  will  get  poor  results.  She  must 
be  able  to  meet  prejudice  with  reason,  to  impose 
her  view  upon  another,  and  to  convince  the  igno- 
rant that  what  she  says  is  right. 

There  is  an  old  fable  which  all  public-health 
nurses  should  remember — the  old  story  of  the 
Wind  and  the  Sun,  who  both  tried  to  remove  the 
Traveller's  cloak.  The  Wind  tried  first,  and  he 
blew  and  blustered,  but  his  frantic  efforts  only 
made  the  Traveller  clutch  it  tighter.  And  then 
the  Sun  tried.  He  shone,  blandly,  warmly,  gently, 
and  in  a  few  moments  off  came  the  cloak.  It  is 
the  method  of  the  Sun,  rather  than  of  the  Wind, 
which  usually  wins  out, 


CHAPTER  XII 

Care  of  the  Family — Examination  of  the  Family — Taking 
Patients  to  Dispensaries — Children — Tuberculosis  in  Child- 
ren— Open-Air  Schools — The  Danger  of  Sending  Patients 
to  the  Country. 

Care  of  the  Family.  We  have  already  said  that 
the  first  consideration  is  the  patient's  family,  or 
those  individuals  who  come  in  contact  with  him. 
Therefore,  as  soon  as  he  himself  is  under  satis- 
factory supervision,  the  nurse  must  turn  her 
attention  to  the  other  members  of  the  household 
who  need  her  even  more.  A  majority  of  the 
nurse's  patients  are  either  advanced  or  last-stage 
cases,  many  of  them  having  a  history  extending 
over  months  or  perhaps  even  years  of  illness.  If 
during  this  time  the  nature  of  the  disease  has  been 
unknown;  or  known,  and  no  precautions  have 
been  taken,  there  is  great  likelihood  that  other 
members  of  the  family  have  also  become  infected. 
To  discover  these  suspicious  cases  and  get  them 
examined  and  under  treatment  as  soon  as  possible, 
is  one  of  the  nurse's  first  responsibilities.  Next, 
she  must  give  careful  attention  to  those  other 

'54 


Care  of  the  Family  155 

members  of  the  family  who  so  far  have  apparently 
escaped.  She  must  not  over-alarm  or  frighten 
them,  but  she  must  keep  before  them  the  fact  that 
they  are  in  close  contact  with  a  highly  infectious 
disease,  and  that  whatever  lowers  their  resistance, 
increases  in  like  manner  their  chances  of  contract- 
ing it.  They  must  employ  every  means  in  their 
power  to  raise  their  vitality  to  a  point  where  they 
cannot  be  reached.  An  infectious  disease  does 
not,  as  a  rule,  gain  entrance  into  a  constitution 
strong  enough  to  resist  it. 

To  this  end,  the  nurse  should  pay  particular 
attention  to  the  personal  hygiene  of  the  exposed 
family.  Their  bedrooms  and  sleeping  quarters 
should  receive  as  careful  consideration  as  do  those 
of  the  patient.  Every  one  in  the  house  should  be 
taught  the  value  of  fresh  air,  and  the  necessity  of 
sleeping  with  wide-open  windows;  the  measures 
needed  to  get  people  well  are  equally  necessary 
to  keep  them  well. 

The  family  also  needs  careful  instruction  as  to 
food  and  rest:  food,  nourishing  and  well  cooked; 
rest,  which  should  at  least  mean  that  at  the  end 
of  a  day's  work  they  do  not  exhaust  their  vitality 
in  crowded  poolrooms,  dance  halls,  and  saloons. 
The  need  of  recreation  is  one  of  the  fundamental 
needs  of  mankind,  but  there  is  a  difference  between 


156         The  Tuberculosis  Nurse 

that  which  refreshes  and  that  which  undermines 
the  constitution.  Whether  this  fatigue  comes 
from  work,  play,  or  excesses  of  any  kind,  it  is 
usually  the  worn-out  individual  who  first  suc- 
cumbs to  exposure.  In  all  households  there  is 
great  need  for  instruction  along  these  lines.  There 
are  weary,  indifferent  parents,  and  heedless  boys 
and  girls  whose  ignorance  of  personal  hygiene  is 
profound.  The  fact  that  much  of  this  teaching 
falls  on  apparently  stony  ground  shows  the  need 
for  redoubled  effort — which  will  in  time  bear  fruit. 
Those  in  contact  with  tuberculosis  must  be  con- 
tinually on  their  guard  against  it — disease  does  not, 
as  a  rule,  attack  those  who  are  in  sound  health. 

In  this  preventive  work,  the  nurse  will  be 
greatly  aided  if  she  knows  what  agencies  she  can 
call  upon  to  reinforce  her  instruction.  She  must  be 
familiar  with  all  the  forces  of  social  service,  and 
know  how  to  reach  them,  and  how  to  place  her 
families  in  touch  with  them.  Just  as  she  must 
have  sufficient  knowledge  of  dietetics  to  suggest 
rice  as  a  substitute  for  cabbage,  bread  instead  of 
pie;  so  must  she  understand  the  social  agencies 
within  call,  and  know  what  substitutes  they  offer 
for  the  things  that  she  condemns.  A  great  gain 
will  have  been  made  if  instead  of  the  poolroom, 
the  young  boy  can  be  given  the  Settlement  club 


Examination  of  the  Family        157 

or  gymnasium;  or  instead  of  the  saloon  dance- 
hall,  the  young  girl  can  be  offered  that  of  the 
schoolroom  or  the  church.  The  aim  should  not 
be  to  deprive,  but  to  substitute.  Preventive 
work  consists  largely  in  teaching  how  to  substitute 
the  harmless  for  the  harmful,  the  healthful  for 
the  unhealthful.  In  some  communities,  no  such 
agencies  exist;  in  others,  they  are  inadequate  to 
the  needs  they  try  to  fill.  But  if  they  exist,  they 
should  be  called  upon. 

Examination  of  the  Family.  Every  person 
constantly  exposed  to  tuberculosis  should  be 
examined  periodically,  whether  or  not  he  presents 
symptoms.  The  nurse  should  endeavour  to  get 
all  members  of  the  patient's  household  examined. 
This  is  sound  in  theory,  but  not  always  feasible 
in  practice,  especially  when  there  are  a  large 
number  of  patients  under  supervision.  When  one 
is  working  with  small  numbers,  with  ten,  twenty, 
or  a  hundred  families,  it  might  be  possible  to  get 
every  member  of  these  households  examined,  but 
when  one  is  working  with  large  numbers  it  becomes 
proportionately  difficult.  In  Baltimore  some  5000 
consumptives  are  annually  dealt  with  by  the 
Tuberculosis  Division;  if  every  one  of  these 
patients  comes  in  contact  with  five  other  persons 
— a  most  modest  estimate — that  would  give  us  a 


158          The  Tuberculosis  Nurse 

total  of  25,000  people  to  bring  forward  for  physical 
examination.  This  task  would  swamp  our  dis- 
pensaries and  leave  no  time  for  anything  else. 
After  all,  it  is  the  positive  rather  than  the  potential 
cases  which  are  a  menace  to  the  community. 
Thus,  however  much  we  may  advocate  the  need 
for  general  examination  of  all  exposed  persons, 
this  course  has  its  drawbacks  when  it  comes  to 
actual  practice.  The  best  we  can  do  is  to  get  the 
suspicious  cases  examined.  The  examination  of 
those  who  have  no  symptoms  would  furnish  in- 
teresting statistics,  but  they  are  hardly  dangerous 
enough  to  the  community  to  warrant  the  outlay  of 
time  and  energy. 

To  induce  a  patient  to  be  examined  often  re- 
quires weeks  or  months  of  effort  and  persuasion. 
The  less  the  apparent  necessity,  the  more  difficult 
it  often  becomes.  If  a  person  has  no  symptoms 
he  will  not  go,  and  if  he  has  symptoms,  he  is 
afraid  to  go,  to  a  physician.  Therefore,  whenever 
it  is  possible  to  get  exposed  persons  examined,  well 
and  good ;  when  this  is  not  possible,  the  nurse  may 
confine  her  efforts  to  those  with  suspicious  symp- 
toms. One  of  the  foremost  requisites  in  this  work 
is  the  ability  to  distinguish  between  essentials  and 
unessentials,  and  having  made  the  distinction,  to 
concentrate  on  the  most  important. 


Children  159 

Taking  Patients  to  Dispensaries.  Unless  the 
nurse  has  abundance  of  time  and  a  very  light 
district,  it  is  not  well  that  she  should  spend  time 
in  taking  reluctant  patients  to  a  dispensary  for 
examination.  To  do  this,  means  to  give  up  from 
one  to  several  hours,  which  she  can  ill  afford  to 
spend  in  this  manner.  Nor  is  it  necessary  to 
waste  her  expert  service  in  this  way — it  is  always 
possible  to  find  some  one  willing  to  take  these 
patients,  some  friendly  visitor,  settlement  worker, 
or  even  a  kindly,  intelligent  neighbour. 

Children.  It  is  conceded  nowadays  that  people 
usually  become  infected  with  tuberculosis  in  the 
first  ten  or  twelve  years  of  life,  or  during  childhood. 
The  disease  itself  may  or  may  not  develop  in  later 
life,  according  to  the  circumstances  or  environ- 
ment in  which  the  individual  is  placed.  It  may 
light  up  later,  if  his  resistance  becomes  lowered, 
or  he  is  reinfected,  and  cannot  carry  the  extra  load. 
For  this  reason,  it  is  a  vastly  important  thing  to 
protect  children  from  infection,  as  well  as  to  protect 
those  exposed  in  childhood  from  later  undue  strain. 

The  children  the  nurse  sees  are  usually  those 
in  contact  with  a  tuberculous  father  or  mother. 
What  is  gained  if  we  teach  the  parent  to  sleep 
alone,  and  spend  part  of  the  time  away  from  them, 
yet  permit  him  at  other  times  to  remain  in  close 


160          The  Tuberculosis  Nurse 

contact  with  the  children?  Intermittent  contact, 
repeated  often  enough,  is  as  bad  as  constant 
contact.  If  a  mother  nurses,  feeds,  cooks  for, 
and  handles  her  child,  there  are  untold  opportuni- 
ties of  infection.  If  the  parent  is  intelligent  and 
unselfish,  it  may  be  possible  to  bring  about  a  rela- 
tive degree  of  carefulness,  and  a  minimum  ex- 
posure, but  there  is  no  such  thing  as  adequate 
carefulness  while  these  conditions  continue. 
Among  the  very  poor,  where  it  is  impossible  to 
regulate  living  conditions,  there  is  practically  no 
doing  away  with  the  danger  of  infection. 

Whenever  the  parents  are  sick,  selfish,  or  igno- 
rant; when  the  children  are  undisciplined  and 
uncontrolled,  and  where  the  grind  of  poverty  has 
reduced  ethics  to  the  most  primitive  basis,  one 
cannot  expect  much.  When  a  child  is  in  constant 
contact  with  a  tuberculous  individual,  no  matter 
how  careful  that  individual  may  try  to  be,  there  is 
always  some  danger.  By  the  very  nature  of  his  dis- 
ease, a  consumptive  cannot  be  a  hundred  per  cent, 
careful.  An  adult  living  in  contact  with  tuber- 
culosis may  be  able  to  resist  it,  a  child  has 
infinitely  less  chance. 

The  only  way  to  ensure  absolute  safety  for  the 
child  is  to  remove  it  from  the  danger,  or  to  remove 
danger  from  it.  Either  the  child  must  be  removed 


Tuberculosis  in  Children          161 

from  the  house,  or  the  patient  must  be  removed 
from  the  house,  it  makes  little  difference  which. 
The  patient  may  be  sent  to  an  institution,  or  the 
child  may  be  sent  to  a  relative,  to  the  country,  to  a 
neighbour,  or  to  one  of  the  child-saving  agencies 
that  are  to  be  found  in  most  communities.  We  are 
aware  that  in  advocating  this  policy  we  are  advo- 
cating what  is  called  by  the  unthinking  "breaking 
up  the  home,"  as  if  tuberculosis  had  not  long  ago 
preceded  us  in  this.  Sending  away  the  parent  or 
the  child  is  merely  a  belated  effort  to  save  what  is 
left  of  the  home. 

Whenever  an  institution  is  possible,  the  patient 
should  go  there.  In  many  communities,  however, 
there  are  no  such  facilities,  or  else  their  capacity 
is  limited.  In  this  case,  the  child  is  the  one  to  be 
removed.  This  often  becomes  a  matter  of  extreme 
difficulty,  since  it  is  hard  to  overcome  the  parent's 
very  natural  resistance.  In  urging  this  separa- 
tion, we  are  making  a  choice  between  two  lives 
—one  already  doomed,  and  the  other  which  may 
be  saved  from  a  similar  fate. 

Tuberculosis  in  Children.  Although  children 
become  infected  at  an  early  age,  it  is  often  most 
difficult  to  obtain  a  diagnosis  for  them.  The  most 
competent  specialist  hesitates  to  pronounce  a  child 
tuberculous  until  he  has  repeatedly  examined  it, 

IX 


162          The  Tuberculosis  Nurse 

and  kept  it  under  constant  observation — and  even 
then  he  may  prefer  to  call  it  "suspicious  only." 
By  the  aid  of  the  eye  test  and  the  skin  test  he 
may  finally  arrive  at  a  positive  diagnosis,  but  even 
then,  he  may  not  be  sure  of  the  location  of  the 
lesion.  The  child,  therefore,  though  diagnostically 
a  positive  case,  is  not  necessarily  an  infectious  one. 

All  these  doubts  and  difficulties  in  connection 
with  the  diagnosis  of  tuberculosis  in  children  serve 
to  show  that  in  a  way  this  question  may  be  called 
a  negligible  one,  negligible,  that  is  to  say,  as  a 
menace  to  public  health.  It  is  important  for  the 
individual  that  a  diagnosis  be  made,  in  order  to 
do  intensive  work  in  upbuilding  his  resistance,  but 
he  is  negligible  as  a  distributor  of  infection.  About 
ten  per  cent,  of  the  visiting  list  is  made  up  of 
children.  On  entering  a  home  where  there  are 
two  children,  one  tuberculous  and  one  not,  the 
nurse's  efforts  should  be  concentrated  on  separat- 
ing the  two — the  emphasis  being  placed  on  the 
care  of  the  one  as  yet  uninfected. 

The  question  frequently  arises,  Should  these 
tuberculous  children  be  sent  to  school?  Is  it 
well  for  them  as  individuals,  from  the  standpoint 
of  their  own  health,  and  is  it  well  for  those  who  are 
thrown  in  contact  with  them?  This  decision 
rests  solely  with  the  physician,  and  can  be  made 


Open-Air  Schools  163 

by  him  alone.  As  far  as  danger  to  others  is  con- 
cerned, it  must  be  remembered  that  while  a  person 
may  be  tuberculous,  he  is  not  necessarily  infec- 
tious, and  it  is  upon  the  infectiousness  of  a  case 
that  the  danger  depends. 

It  is  difficult  to  care  for  these  tuberculous 
children.  Most  nurses  become  deeply  distressed 
because  of  this.  The  children  are  frequently 
undisciplined,  and  their  parents  often  weak  and 
lacking  in  self-control.  The  nurse  becomes  dis- 
couraged and  annoyed  when  she  sees  her  directions 
unheeded  or  disobeyed.  But,  after  all,  these  cases 
constitute  but  a  minor  part  of  the  problem,  and 
they  are  not  patients  who  do  much  harm.  It  is 
sad  to  stand  by  and  see  the  individual  throw  away 
his  chances,  or  to  see  them  thrown  away  for  him 
— but  this  standing  by  is  part  of  the  work. 

Open-Air  Schools.  During  the  past  five  or  six 
years,  open-air  schools  or  classrooms  have  been 
established  in  several  of  our  large  cities.  This  is 
an  excellent  affirmative  answer  as  to  whether  a 
tuberculous  child  should  attend  school.  At  these 
places,  careful,  systematic  attention  is  given  the 
child  for  several  hours  a  day.  Non-tuberculous 
children  are  also  admitted — they  may  be  called 
pre-tuberculous,  since  they  are  anaemic,  run-down, 
undernourished  children,  who  come  from  homes 


164          The  Tuberculosis  Nurse 

where  tuberculosis  exists  in  active  form.  For 
such  cases,  the  open-air  school  does  excellent 
preventive  work,  in  raising  the  child's  resistance 
to  a  point  where  it  can  cope  with  the  exposure  at 
home.  These  open-air  classes  are  always  in 
charge  of  a  physician  and  a  nurse;  their  manage- 
ment does  not  come  within  the  range  of  this  dis- 
cussion, any  more  than  does  that  of  the  hospital 
or  the  sanatorium. 

The  public  health  nurse  must  always  take 
advantage  of  these  schools,  if  they  exist,  and  must 
see  that  her  children  are  sent  there.  She  must 
avail  herself  of  every  agency  and  of  every  oppor- 
tunity which  will  improve  or  secure  the  welfare 
of  those  under  her  charge. 

Schools  of  this  kind  are  extremely  valuable,  but 
are  not  the  solution  of  the  tuberculosis  problem, 
any  more  than  the  sanatorium  for  the  early  case 
is  its  solution.  Both  of  these  institutions  deal  with 
results,  not  causes.  To  fight  tuberculosis,  we 
must  strike  deep  at  the  cause  —  the  advanced 
case  who  scatters  the  disease.  Open-air  schools 
always  make  a  strong  appeal  to  people — it  is  easy 
to  obtain  money  to  support  them,  and  easy  for 
public  sentiment  to  exaggerate  their  value  in  the 
anti -tuberculosis  campaign.  Since  the  public 
mind  generally  grasps  but  one  idea  at  a  time,  it  is 


Danger  of  Sending  Patients  Away  165 

not  well  to  dissipate  its  facile  interest  on  side 
issues.  When  a  community  has  established  on 
adequate  scale  the  machinery  for  combating 
tuberculosis,  it  may  then  establish  such  effective 
allies  as  the  open-air  school.  But  to  bring  them  on 
first,  before  the  fundamentals,  is  to  misdirect  public 
sentiment,  and  to  place  the  cart  before  the  horse. 

The  Danger  of  Sending  Patients  to  the  Country. 
Sooner  or  later,  the  nurse  will  be  called  upon  to 
decide  whether  the  tuberculous  patient  shall  be 
sent  to  the  country.  This  will  be  urged  by  earnest, 
well-meaning  people — and  sometimes  by  social 
workers  who  should  know  better.  Needless  to 
say,  this  policy  calls  for  strong  condemnation. 
Whatever  good  the  patient  himself  might  gain 
from  going  to  the  country,  must  be  offset  by  the 
fact  that  the  disease  is  spread  elsewhere.  To 
create  new  centres  of  infection  is  not  the  result  at 
which  the  tuberculosis  campaign  is  aimed. 

In  his  own  home,  under  immediate  and  constant 
supervision,  it  is  difficult  to  obtain  from  the 
patient  anything  better  than  relative  carefulness. 
To  get  even  that  requires  unceasing  vigilance  and 
continual  training,  both  of  the  patient  and  of  his 
family.  Therefore,  to  free  him  of  this  restraint 
by  sending  him  to  a  distant  farm,  would  mean 
his  immediate  relapse  into  carelessness,  and  a 


166          The  Tuberculosis  Nurse 

danger  to  those  among  whom  he  is  quartered. 
To  send  a  consumptive  into  another  household  is  to 
send  him  where  he  may  infect  other  people.  Pity 
for  the  patient  should  not  obscure  our  interest 
in  his  possible  victims. 

Moreover,  the  welfare  of  the  patient  himself 
is  not  as  a  rule  secured  by  this  method.  These 
journeys  to  the  "country"  are  usually  to  out-of- 
the-way  little  farm-houses,  with  various  short- 
comings both  as  to  food  and  accommodation. 
They  are  often  anything  but  satisfactory  places 
for  a  sick  man;  or,  if  they  happen  to  possess 
advantages,  the  patient  may  not  know  enough  to 
use  them.  In  making  these  statements,  we  are 
not  speaking  entirely  at  random,  or  from  general 
surmises  as  to  probabilities.  A  few  years  ago,  we 
had  on  our  visiting  list  some  fifty-five  patients 
who  went  to  the  country  for  the  summer.  They 
were  in  all  stages  of  the  disease,  and  it  is  well  to 
note,  in  this  connexion,  that  it  is  usually  the 
advanced  case  who  is  most  anxious  to  get  away. 
Of  the  fifty-five  cases,  two  were  really  benefited 
by  their  sojourn;  thirteen  were  temporarily  im- 
proved, but  lost  it  all  within  a  few  weeks  after 
their  return ;  thirty-two  came  back  to  town  worse 
than  when  they  went  away,  and  eight  died  while 
in  the  country. 


Danger  of  Sending  Patients  Away  167 

Of  these  fifty -five  removals,  it  is  safe  to  assume 
that  fifty -five  centres  of  infection  were  established 
in  consequence.  The  families  where  they  were 
quartered  were  doubtless  unaware  of  the  nature 
of  the  disease,  or  how  to  protect  themselves  in  any 
way.  Nor  is  it  likely  that  any  of  these  fifty -five 
farm-houses  were  afterwards  properly  cleaned  or 
disinfected.  It  was  of  course  impossible  to  follow 
the  results  in  these  scattered  centres  of  infection — • 
remote  counties  of  Maryland  and  Virginia — but 
we  succeeded  in  doing  so  in  one  instance  out  of  the 
fifty-five.  In  this  case,  the  patient  had  gone  to  a 
farm  in  Virginia;  as  a  result  of  his  visit,- three 
members  of  a  hitherto  healthy  family  became 
infected,  all  of  whom  have  since  died,  as  well  as 
the  original  patient,  the  "city  boarder"  who 
carried  infection  among  them. 

Of  course,  if  patients  insist  upon  going  to  the 
country,  nothing  can  prevent  them,  although  the 
nurse  must  do  her  best  to  dissuade  them.  One 
patient  who  had  a  large  airy  room  in  town,  de- 
cided that  she  would  be  better  off  on  a  farm.  She 
was  questioned  as  to  conditions  at  the  farm,  and 
it  transpired  that  she  was  to  occupy  an  attic  room, 
with  one  window,  and  that  this  room  was  to  be 
shared  with  three  other  people.  It  then  became 
an  easy  matter  to  dissuade  her  from  going.  It  is 


1 68          The  Tuberculosis  Nurse 

not  always  thus  easy  to  deflect  them.  Should  they 
insist,  they  should  be  given  plentiful  supplies, 
and  if  the  nurse  can  obtain  the  address  of  the 
family  where  they  are  to  stay,  she  should  send  full 
information  as  to  the  patient's  condition.  It  is  a 
regrettable  fact,  but  when  a  patient  is  removed 
from  surroundings  where  his  condition  is  known, 
he  is  apt  to  discard  his  sputum  cup  and  all  other 
precautions  by  which  he  is  rendered  conspicuous. 
We  cannot  be  too  emphatic  in  refusing  to  send 
consumptives  to  the  country.  If  a  sanatorium  or 
day  camp  is  not  available,  they  would  better 
remain  in  the  city.  If  the  patient  has  money,  he 
cannot  of  course  be  prevented  from  going.  If  he 
has  no  money,  no  appeal  should  be  made  for  funds 
to  send  him  away.  To  ask  for  money  for  such  use 
is  a  wrong  the  public  health  nurse  should  have 
no  hand  in.  Her  business  is  to  prevent  scattering 
infection,  not  to  aid  in  it. 


CHAPTER  XIII 

Disinfection  of  Houses — Value  of  Fumigation — Formaldehyde — 
House-Cleaning  —  Burning  and  Sterilizing — Boiling  —  Car- 
pets, Rugs,  and  Mattings — Painting,  Papering,  and  White- 
washing— Temporary  Removals — Vacant  Houses — Com- 
pulsory Cleaning. 

Disinfection  of  Houses.  One  of  the  most 
important  of  the  nurse's  duties  is  her  arrangement 
for  the  fumigation  and  cleaning  of  premises  that 
have  been  vacated  by  a  consumptive.  This  takes 
place  after  death,  or  upon  the  patient's  removal 
to  an  institution,  to  another  house,  or  to  another 
room  in  the  same  house. 

Since  tubercle  bacilli  are  not  confined  to  the 
sputum,  but  are  discharged  in  great  numbers 
during  coughing  attacks,  and  to  a  less  extent 
during  sneezing,  speaking,  and  so  forth,  a  patient 
not  confined  to  one  room,  but  who  wanders  freely 
about  the  house,  scatters  bacilli  everywhere.  No 
matter  how  careful  he  may  be  about  the  sputum, 
the  nature  of  the  disease  makes  it  practically 
impossible  to  be  equally  careful  about  the  expired 
air.  Moreover,  these  organisms  do  not  die  of 

169 


170          The  Tuberculosis  Nurse 

themselves,  at  the  end  of  a  few  weeks.  They  are 
singularly  tenacious  and  persist  for  months, 
virulent  and  active.  A  case  is  recorded  in  which 
they  were  found  in  a  room  six  months  after  the 
patient's  removal,  alive  and  virulent  enough  to 
cause  tuberculosis  in  guinea-pigs  inoculated  with 
them.  For  this  reason  it  takes  drastic  measures 
to  rid  a  house  of  these  tenacious  germs. 

In  indicating  the  rooms  to  be  fumigated,  it  is 
necessary  to  include  all  those  that  have  been 
occupied  by  the  patient  within  the  past  six  months. 
If  he  dies  in  his  bedroom,  it  is  not  enough  to  do 
merely  that  one  room.  It  is  equally  necessary  to 
fumigate  the  kitchen,  in  which  he  sat  until  two 
months  ago;  the  parlour,  where  he  spent  a  few 
hours  a  day,  and  the  second  bedroom,  to  which 
he  was  now  and  then  removed.  All  are  infected, 
and  all  need  the  utmost  care  to  free  them  from 
germs.  The  family  must  be  taught  why  these 
rooms  are  dangerous,  and  made  to  understand 
the  necessity  for  full  and  complete  disinfection. 
It  is  better  to  err  on  the  side  of  too  much,  rather 
than  of  too  little  care. 

In  Baltimore,  the  actual  fumigation  is  not  done 
by  the  nurses,  but  by  the  employees  of  the  Fumi- 
gation Division  of  the  Health  Department.  The 
nurse  indicates  the  rooms,  instructs  the  family, 


Disinfection  of  Houses  171 

and  makes  all  the  preliminary  arrangements,  after 
which  she  reports  the  premises  to  the  fumigator, 
who  disinfects  them  next  day.  It  would  be  well 
if  this  fumigation  could  be  done  by  the  nurses  or 
by  a  special  corps  of  nurses ;  this  would  probably 
ensure  more  intelligent  and  conscientious  work 
than  that  which  the  average  city  employee  bestows 
upon  this  important  task. 

As  a  matter  of  routine,  every  death  from  pul- 
monary tuberculosis  is  reported  to  the  Tubercu- 
losis Division;  the  nurse  in  whose  district  this 
death  has  occurred  then  inspects  the  house  and 
arranges  for  the  fumigation.  Four  times  out  of 
five  the  patient  is  already  known  to  us  and  already 
under  supervision,  which  makes  the  duty  easier 
than  if  he  were  unknown.  In  either  case,  however, 
the  nurse  visits  the  home  and  arranges  all  the 
details. 

In  like  manner,  all  patients  who  enter  either 
hospital  or  sanatorium  are  reported  to  the  Health 
Department,  the  institutions  furnishing  their 
names  and  addresses  so  that  the  fumigation  may 
be  attended  to.  When  a  patient  changes  his 
address  and  moves  to  other  quarters,  the  nurse 
is  the  only  one  who  knows  of  this  change,  hence 
it  is  her  responsibility  to  report  these  houses  and 
see  that  they  are  fumigated.  To  arrange  for  all 


172         The  Tuberculosis  Nurse 

these  fumigations,  whether  after  death  or  after 
removal,  means  that  a  large  amount  of  time  is 
spent  upon  this  work  of  trying  to  rid  the  com- 
munity of  dangerous  centres  of  infection. 

Value  of  Fumigation.  The  actual  value  of 
fumigation  is  a  debatable  point.  Under  the  best 
conditions,  its  efficacy  is  not  a  hundred  per  cent. — • 
far  from  it — while  under  unfavourable  conditions, 
when  poorly  done,  its  efficacy  is  so  low  as  to  be 
almost  nil.  The  house  whose  cracks  have  been 
improperly  stopped,  and  the  old  house,  with  open 
chimneys,  loose  windows,  and  apertures  which 
cannot  be  closed,  are  not  made  safe  by  this  pro- 
cess. Under  such  conditions,  fumigation  not 
only  fails  to  remove  the  danger,  but  it  produces  a 
false  sense  of  security.  Unless  properly  done,  it 
were  better  not  to  do  it  at  all.  We  should  prefer 
instead  to  depend  upon  vigorous  house-cleaning, 
the  use  of  hot  water,  soap,  and  the  scrubbing 
brush,  and  the  destruction  of  all  infective  material. 
Moreover,  even  under  the  best  conditions,  form- 
aldehyde has  no  powers  of  penetration.  Its 
action  is  purely  superficial,  and  only  useful  for 
plane  surfaces,  such  as  walls,  ceilings,  and  so 
forth.  The  most  dangerous  articles,  such  as 
clothing,  carpets,  bedding,  and  the  like,  are  totally 
unaffected  by  it.  We  ought  to  stop  teaching 


Formaldehyde  173 

that  fumigation  alone  will  clear  up  these  infected 
houses  and  make  them  safe  for  future  habitation. 
The  public  has  been  misled  as  to  the  value  of  this 
measure,  and  allowed  to  place  far  more  reliance 
upon  it  than  has  been  justified  by  experience. 
It  is  high  time  for  enlightenment.  The  most 
that  can  be  said  for  fumigation  is  that  undoubted- 
ly it  kills  some  germs — so  many  that  it  is  worth 
while  to  continue  the  practice  of  it,  but  too  few  to 
afford  adequate  protection.  It  must  be  supple- 
mented by  other  and  more  radical  measures. 

Formaldehyde.  Formaldehyde  in  one  of  its 
preparations  is  the  chemical  most  generally  used, 
and  is  more  valuable  than  sulphur,  which  is  now 
discarded.  In  most  cities,  the  Health  Depart- 
ment attends  to  the  fumigation.  In  small  towns 
or  rural  districts,  where  there  is  no  fumigating 
corps,  formaldehyde  is  usually  given  upon  applica- 
tion to  the  local  or  State  Board  of  Health.  In 
some  localities,  especially  in  country  districts, 
there  may  be  no  appropriation  for  this  disinfect- 
ant, which  the  householder  must  then  buy  himself.  * 

1  There  are  many  formaldehyde  preparations  on  the  market, 
simple  and  easy  to  use,  but  these  may  be  unobtainable.  In  this 
case,  an  effective  method  is  the  combination  of  formaldehyde 
with  potassium  permanganate.  For  a  room  containing  1000 
cubic  feet  of  air  space  (a  room  10  feet  long,  10  feet  wide,  and 
10  feet  high),  the  amount  needed  is:  Potassium  permanganate, 
oz.  in.;  liquid  formaldehyde,  pint  i.  Place  the  formaldehyde  in  a 


174          The  Tuberculosis  Nurse 

Since  fumigation  is  only  a  matter  of  six  hours' 
duration,  it  will  cause  no  great  hardship  or  incon- 
venience to  the  family  which  for  this  short  period 
must  be  turned  out  of  the  house.  Yet  many 
people  complain  bitterly  over  this  trial,  and  raise 
every  possible  objection.  They  are  willing  enough 
to  have  one  room  done,  but  refuse  to  allow  more. 
The  nurse  must  explain  that  a  six  hours'  incon- 
venience is  better  than  risking  health  and  life, 
and  she  should  also  explain  that  in  insisting  upon 
fumigation  the  Health  Department  is  neither 
arbitrary  nor  vindictive.  Fumigation  is  a  rather 
costly  affair,  and  this  expense  is  incurred,  not  to 
annoy  but  to  protect  the  community.  In  win- 
ning over  a  reluctant  family  she  has  a  chance  to 
do  excellent  educational  work.  It  is  always  bet- 
ter to  secure  their  intelligent  co-operation,  even 
though  it  take  long  and  patient  argument,  than 
to  end  the  discussion  by  abruptly  informing  them 
that  fumigation  is  compulsory,  and  will  be  done 
whether  desired  or  not. 

House-Cleaning.  Fumigation  must  always  be 
followed  by  most  searching  and  thorough  house- 
cleaning,  which  important  task  must  be  done  by 

large  galvanized  iron  bucket  (holding  8  to  10  quarts),  and  drop 
the  permanganate  into  it.  The  room  should  be  left  closed  for 
six  hours;  a  longer  time  is  unnecessary,  a  shorter  time  ineffectual. 
All  cracks,  of  course,  should  have  been  previously  stopped. 


Burning  and  Sterilizing          175 

the  family  itself.  All  floors  should  be  scrubbed 
with  hot  water  containing  lye  or  soda  solution 
and  all  washable  surfaces  should  be  likewise 
treated.  This  includes  furniture,  doors,  door 
knobs,  windows,  stairs,  banister  rails,  and  so 
forth.  The  necessity  for  this  house-cleaning  can- 
not be  too  strongly  emphasized. 

Burning  and  Sterilizing.  The  most  highly 
infective  material  is  the  bedding,  mattress,  pil- 
lows, clothing,  and  so  forth,  which  have  been  used 
by  the  patient.  Since  these  articles  cannot  be 
made  safe  by  formaldehyde  fumigation,  and  since 
most  of  them  cannot  be  washed  and  boiled,  there 
are  but  two  methods  of  disposal.  The  most 
drastic  and  wasteful  is  to  burn  them,  yet  this  must 
always  be  advised  unless  we  can  offer  the  alterna- 
tive of  sterilization  under  high  pressure  steam. 
To  burn  infective  material  involves  a  loss  which 
few  people  can  afford,  and  they  are  loth  to  make 
the  sacrifice;  most  of  these  articles,  while  laden 
with  germs,  are  nevertheless  serviceable  and  in 
good  condition.  To  expect  that  they  will  be 
burned,  therefore,  is  to  expect  the  impossible. 
If  the  family  consent  to  destroy  certain  articles, 
they  reserve  others,  equally  unsafe  for  use.  The 
only  alternative  is  the  municipal  sterilizer,  and 
any  community  which  expects  to  do  effective 


176         The  Tuberculosis  Nurse 

preventive  work  must  establish  this  as  a  factor  of 
first  importance. 

In  Baltimore  there  is  such  a  sterilizer,  and  the 
use  of  it  is  very  simple.  When  the  nurse  arranges 
about  the  fumigation,  she  selects  at  the  same  time 
whatever  articles  are  to  be  sterilized — pillows, 
mattresses,  blankets,  clothing,  and  so  forth.  These 
are  then  called  for  by  the  men  from  the  Fumiga- 
tion Division.  They  are  placed  in  large  canvas 
bags,  inventoried,  labelled,  and  carried  to  the 
sterilizer.  Here  they  are  steamed  and  dried, 
and  returned  a  day  or  two  later  in  good  condition. 
The  householder  signs  a  receipt  to  this  effect.  * 

Unfortunately,  steam  sterilizing  plants  are 
rare,  and  in  most  communities  the  nurse  will  have 
to  protect  her  patients  in  other  ways.  As  we  have 
said  before,  the  only  alternative  is  burning,  and 
this  often  works  great  hardship  on  many  families. 
With  the  very  poor,  the  Federated  Charities  may 
be  called  upon  to  supply  new  mattresses,  etc.,  in 
place  of  those  that  have  been  destroyed,  and  as 

1  Certain  articles  are  ruined  by  sterilization,  and  the  nurse 
must  be  careful  not  to  include  these,  or  there  will  be  a  suit  for 
damages.  Leather  and  furs,  can  never  be  steamed.  Straw  mat- 
tresses are  also  injured.  Nor  is  it  possible  to  sterilize  carpets 
and  matting,  because  of  their  bulk.  The  sterilizer  should  be  re- 
served exclusively  for  material  which  lends  itself  readily  to  treat- 
ment of  this  kind.  In  selecting  what  is  suitable,  the  nurse  should 
exclude  old  and  filthy  articles,  which  should  be  burned. 


Burning  and  Sterilizing          177 

a  rule  this  response  is  prompt.  Yet  there  are 
many  cases  where  the  family  is  too  poor  to  suffer 
this  loss,  yet  not  poor  enough  to  come  within 
range  of  a  charitable  association.  These  cases 
constitute  a  difficult  problem — a  problem  that  is 
entirely  solved  only  by  the  municipal  sterilizer. 

Except  through  sterilization,  there  is  no  way 
in  which  these  articles  may  be  made  safe.  Car- 
bolizing  will  not  do  this,  neither  will  sunshine. 
Valuable  as  sunshine  is,  it  is  difficult  to  secure 
prolonged  exposure,  especially  in  tenement  dis- 
tricts. It  is  possible,  of  course,  to  take  a  mattress 
apart  and  wash  and  boil  the  ticking;  feathers  or 
hair  may  be  sent  to  an  upholsterer,  who  has  means 
of  steaming  them.  Pillows  may  be  put  into  a 
large  wash-boiler,  and  boiled  for  half  an  hour,  after 
which  they  may  be  washed — it  will  take  a  week  or 
more  before  they  become  thoroughly  dry  and 
usable.  All  these  alternatives  involve  a  great 
outlay  of  time  and  energy,  and  we  cannot  but  feel 
sceptical  as  to  the  thoroughness  with  which  this 
cleaning  is  likely  to  be  done.  A  family  which 
objects  to  parting  with  dangerous  articles,  and 
prefers  risk  to  inconvenience  or  deprivation,  is 
hardly  likely  to  be  scrupulous  as  to  details  of  this 
character. 

In  Baltimore,  before  the  advent  of  the  steam 


178          The  Tuberculosis  Nurse 

sterilizer,  the  amount  of  material  burned  was  never 
more  than  a  third  of  the  amount  which  should 
have  been  burned.  Still,  under  the  circumstances, 
we  were  thankful  to  have  achieved  this  third. 
Since  the  establishment  of  the  sterilizer,  we  now 
succeed  in  getting  over  two  thirds  (70  per  cent.) 
of  the  infective  material  sterilized.  This  is  a 
triumph  for  the  nurse's  teaching,  since  there  is  no 
law  making  sterilization  compulsory. 

Boiling.  Everything  which  can  be  boiled  will 
of  course  be  made  safe,  whether  these  articles  be 
of  wool,  linen,  china,  rubber,  etc.  Even  blankets 
may  be  boiled,  although  the  family  will  object  to 
this  on  the  ground  that  it  shrinks  them.  The 
nurse  must  explain  that  not  to  boil  them  may 
have  consequences  even  more  disastrous.  The 
nurse  must  never  permit  her  patients  to  make 
indiscriminate  bonfires,  and  wantonly  destroy 
harmless  articles,  or  those  which  may  readily  be 
made  so.  We  know  one  family  which  destroyed  a 
whole  set  of  dishes,  not  from  painful  association, 
but  from  a  misdirected  desire  to  do  the  right  thing. 
For  this  reason,  the  nurse  must  look  over  all 
articles  carefully,  giving  thoughtful  counsel  as  to 
the  proper  disposition  of  each. 

Carpets,  Rugs,  and  Mattings.  As  the  sterilizer 
cannot  be  used  for  carpets,  rugs,  and  mattings, 


Temporary  Removals  179 

there  is  nothing  to  do  but  advise  that  these  articles 
be  burned.  As  a  rule,  this  destruction  is  agreed 
to  with  more  readiness  than  in  the  case  of  pillows 
and  mattresses. 

Painting,  Papering,  and  Whitewashing.  When- 
ever possible,  the  rooms  used  by  a  consumptive 
should  be  repapered,  painted,  or  whitewashed  as 
the  case  may  be.  The  more  thorough  and  com- 
plete the  measures  taken  to  eliminate  tubercu- 
losis, the  greater  the  chances  of  success.  It  is  a 
costly  disease,  and  costly  measures,  both  as  to 
money,  energy,  and  time,  are  required  to  get  rid 
of  it.  Half-way  methods  are  poor  economy. 

Temporary  Removals.  The  foregoing  directions 
apply  mainly  to  those  cases  in  which  the  patient 
has  either  died,  or  has  been  permanently  removed 
elsewhere.  If  his  return  is  not  expected  (as 
when  an  advanced  case  enters  the  hospital),  the 
amount  of  cleaning,  burning,  repapering,  etc., 
would  naturally  be  as  great  as  that  required  after 
death. 

On  the  other  hand,  when  his  removal  is  but 
temporary  and  the  patient  expects  to  return  home 
after  a  few  months,  the  amount  of  disinfection 
would  be  considerably  modified.  When  he  enters 
a  sanatorium,  his  house  must  be  fumigated  and 
cleaned,  so  that  for  a  few  months  at  least  the  family 


i8o          The  Tuberculosis  Nurse 

may  be  relieved  of  danger.  Under  such  circum- 
stances, it  would  not  be  necessary  to  counsel  the 
destruction  of  the  mattress  and  bedding  that  he  is 
to  use  upon  his  return.  Meanwhile,  no  other 
member  of  the  family  should  use  these  things, 
although  in  certain  instances  it  is  almost  impossible 
to  prevent  their  doing  so.  For  such  cases  the 
municipal  sterilizer  is  needed — indeed  no  com- 
munity can  make  much  headway  against  tuber- 
culosis until  it  provides  a  means  of  removing  the 
danger  without  causing  loss  to  the  individual. 

Vacant  Houses.  When  a  family's  removal 
leaves  a  vacant  house,  there  is  naturally  no  one 
left  to  do  the  cleaning.  The  Health  Department 
will  do  the  fumigation,  but  the  more  essential 
house-cleaning  remains  undone.  These  houses 
often  stand  idle  for  weeks  or  months  before  finding 
a  new  tenant.  Even  if  it  were  possible  to  discover 
the  landlord  or  owners  (a  task  which  in  itself 
would  require  a  staff  of  employees),  it  is  doubtful 
whether  they  would  clean  these  houses  themselves, 
or  notify  their  new  tenants  of  the  need  for  extra 
vigilance.  Legislation  compelling  house-cleaning 
would  be  difficult  to  put  through.  The  landlord 
feels  relieved  of  all  responsibility  when  once  the 
fumigation  is  accomplished,  and  that  this  fumiga- 
tion is  not  a  hundred  per  cent,  effective  is  no  con- 


Concessions  181 

cern  of  his.  He,  together  with  the  general  public, 
has  been  misled  as  to  its  true  value.  Nor  is 
thorough  cleaning,  painting,  and  papering  an 
expense  that  he  would  willingly  incur.  The 
question  of  the  fumigated  but  not  necessarily  safe 
house  is  one  that  causes  considerable  anxiety. 
We  feel  that  the  only  way  to  deal  with  it,  is  that 
the  nurse  keep  these  vacant  houses  on  her  visiting 
list,  so  to  speak,  and  watch  for  the  time  when  they 
are  re-let.  This  entails  considerable  loss  of  time, 
which  she  can  ill  afford  to  spare  from  her  patients, 
but  the  information  she  can  give  the  new  tenant 
will  have  distinct  preventive  value.  She  must 
tell  the  newcomer  that  he  has  moved  into  a  house 
in  which  there  has  been  tuberculosis,  and  that 
only  by  the  most  exact  and  painstaking  efforts 
can  it  be  made  safe. 

Concessions.  In  carrying  out  this  important 
work,  the  nurse  sometimes  becomes  so  enthusiastic 
that  her  common -sense  gives  way  under  the  strain. 
She  wishes  to  carry  her  point,  without  fully  realiz- 
ing the  prejudices,  ignorances,  sometimes  even  the 
comfort,  of  the  family  she  is  dealing  with.  After 
a  death,  she  comes  upon  a  household  in  a  most 
upset,  distressed,  and  often  irresponsible  condition, 
and  she  must  be  very  gentle  and  patient  in  her 
relations  with  them.  She  must  accomplish  what 


182         The  Tuberculosis  Nurse 

is  necessary,  without  undue  disturbance  of  their 
prejudices  and  feelings.  For  example :  Orthodox 
Jewish  people  observe  a  mourning  period  of  several 
days  following  death,  during  which  time  they 
wish  to  remain  undisturbed.  Fumigation  should 
be  postponed  until  this  time  is  past.  A  few  days' 
delay  will  not  injure  the  health  of  a  family  which 
has  been  exposed  to  infection  for  months.  By 
thus  respecting  their  religious  customs,  it  will  be 
possible  to  gain  better  co-operation  as  to  cleaning 
and  so  forth ;  co-operation  which  would  have  been 
jeopardized  by  riding  roughshod  over  their  feel- 
ings and  beliefs. 

Sometimes  people  raise  objections  because  they 
have  nowhere  to  go  for  the  six  hours  required  for 
fumigation,  during  which  time  they  must  leave 
the  house.  If  there  is  no  kindly  neighbour  to 
take  them  in,  the  nurse  may  arrange  with  a  Settle- 
ment or  other  social  agency,  to  give  them  shelter. 
We  have  often  asked  for  hospitality  in  this  way, 
and  have  always  met  a  ready  response.  Some- 
times, if  a  house  is  a  large  one,  it  is  possible  to 
have  it  fumigated  in  sections,  a  few  rooms  being 
done  one  day,  a  few  the  next. 

Compulsory  Cleaning.  In  most  communities, 
fumigation  is  compulsory.  But  there  is  no  regula- 
tion whatever  concerning  the  after-care  of  the 


Compulsory  Cleaning  183 

premises — the  cleaning,  sterilization,  and  destruc- 
tion of  infective  material.  The  relatively  un- 
important part  is  obligatory,  while  the  essential 
part  is  optional.  And  that  this  essential  part  is 
done,  and  well  done,  depends  almost  entirely  upon 
the  teachings  of  the  public-health  nurse. 

If,  however,  the  family  remains  obdurate,  refus- 
ing to  clean  and  disinfect,  nothing  can  be  done. 
Since  it  is  now  generally  acknowledged  that 
fumigation  falls  far  short  of  what  it  was  once 
expected  to  do,  we  need  laws  making  adequate 
disinfection  compulsory;  until  such  laws  are  en- 
acted, we  can  only  rely  on  the  ability  of  the  nurse 
to  teach  the  necessity  for  cleaning  and  disinfecting. 
How  valuable  is  this  teaching  may  be  gathered  from 
these  figures  (Report,  1913,  Tuberculosis  Division 
of  the  Baltimore  Health  Department):  "After 
death:  houses  cleaned,  80  per  cent.;  bedding,  etc., 
either  burned  or  sterilized,  70  per  cent."  With 
adequate  laws,  the  nurses  would  make  even  a 
better  showing. 


CHAPTER  XIV 

The  Tuberculosis  Dispensary — Equipment — Medicines — Hours 
— Consideration  of  Patients — Function  of  the  Dispensary — 
The  Physician's  Service — The  Physician's  Qualifications 
— The  Physician  and  the  Patient — Duties  of  the  Nurse — 
Tuberculin  Classes — The  Nurse  in  Home  and  Dispensary — 
The  Nurse  as  an  Asset  to  the  Community. 

The  Tuberculosis  Dispensary.  No  community 
can  make  definite  progress  against  tuberculosis 
until  it  establishes  a  place  where  suspicious  pa- 
tients may  be  sent  for  examination  and  diagnosis. 
Unless  this  disease  be  promptly  and  definitely 
recognized,  it  is  impossible  to  give  advice,  or  take 
authoritative  action  concerning  the  treatment  of 
the  patient  and  his  family.  If  in  connection  with 
the  dispensary  there  was  also  a  corps  of  municipal 
physicians,  who  could  visit  the  patients  in  their 
homes,  and  examine  all  suspects  called  to  their  at- 
tention, diagnoses  could  be  obtained  even  more 
promptly.  As  it  is  now,  considerable  interval  often 
elapses  between  the  time  when  the  patient  is  ad- 
vised to  go  to  a  dispensary,  and  the  time  when  he 
follows  this  advice.  The  existence  of  a  corps  of  vis- 

184 


Equipment  185 

iting  physicians  would  prevent  such  delays.  The 
patient  would  be  allowed  a  reasonable  time  in  which 
to  present  himself,  at  the  expiration  of  which  period 
he  would  be  sought  out  by  the  officer  of  the  mu- 
nicipality. This  prompt  recognition  of  tuberculosis 
would  save  the  community  from  an  enormous 
amount  of  exposure.  The  time  may  yet  come 
when  Departments  of  Health  will  see  the  wisdom 
of  such  measures. 

Until  that  time,  the  special  dispensary  repre- 
sents the  only  means  of  obtaining  a  diagnosis; 
it  is  the  only  place  where  patients  may  freely  be 
sent,  and  where  an  expert  and  frank  opinion  may 
be  had.  Such  a  dispensary  may  be  established 
in  connection  with  the  general  dispensary  of  a 
hospital,  or  by  the  local  Health  Department,  or  it 
may  be  supported  by  the  same  group  of  people  or 
association  which  supports  the  special  nurse.  In 
Baltimore,  we  have  had  dispensaries  of  all  three 
kinds,  and  the  nurses  have  worked  in  connection 
with  each  one,  on  exactly  the  same  terms. 

Equipment.  The  great  tuberculosis  dispen- 
saries run  in  connection  with  the  large  hospitals 
and  medical  schools  are  usually  very  completely 
and  elaborately  equipped.  They  contain  large 
waiting  rooms,  examining  rooms,  special  rooms 
for  the  giving  of  tuberculin,  for  X-ray  examina- 


1 86          The  Tuberculosis  Nurse 

tions,  for  throat  examinations,  for  laboratory 
work,  and  so  forth.  All  these  are  needed  in 
teaching  centres,  where  it  is  necessary  to  collect 
certain  scientific  data.  But  for  the  purpose  of 
making  an  ordinary  physical  examination  a  simpler 
equipment  will  do  equally  well. 

In  Baltimore  there  are  several  small  municipal 
dispensaries,  all  under  the  control  of,  and  managed 
by,  the  Department  of  Health.  They  are  situated 
in  different  parts  of  the  city,  readily  accessible  to 
the  patients  of  different  localities.  Each  dispen- 
sary consists  of  two  or  three  rooms,  which  are 
in  the  same  building  which  houses  the  Federated 
Charities,  and  other  social  agencies.  This  ar- 
rangement has  several  advantages,  from  the 
point  of  view  of  both  economy  and  co-operation. 
To  have  rented  similar  rooms  in  another  building 
or  in  a  private  house  would  have  meant  a  much 
greater  outlay  of  money,  to  say  nothing  of  the  op- 
position encountered  in  obtaining  the  use  of  these 
rooms  for  dispensary  purposes. 

The  furnishings  of  these  little  municipal  dis- 
pensaries are  extremely  simple,  but  they  lack 
nothing  of  comfort  and  convenience.  The  outer 
or  waiting  room  contains  two  or  three  dozen 
chairs,  or  benches  to  accommodate  an  equal 
number  of  people.  A  corner  of  this  room  is 


Medicines  187 

screened  off  for  the  nurse's  table,  where  she  keeps 
her  charts  and  records,  and  writes  the  patients' 
histories.  A  couple  of  filing  cabinets,  a  medicine 
closet,  and  a  pair  of  scales  complete  the  outfit. 

The  inner,  or  examining  room,  is  also  simple 
and  inexpensively  furnished.  It  is  divided  into 
several  compartments  by  means  of  gas  piping, 
each  compartment  being  large  enough  to  hold  a 
revolving  stool  and  a  wicker  lounge.  Unbleached 
muslin  curtains  hang  from  these  gas-pipe  rods, 
making  several  little  cubicles  in  which  the  patients 
are  examined.  It  is  thus  possible  for  the  doctor 
to  examine  a  patient  in  one  cubicle,  while  another 
patient  undresses  in  the  adjoining  one — an  arrange- 
ment which  saves  considerable  time.  Sheets, 
towels,  and  blankets  complete  the  necessary 
furnishings,  which  may  be  cheap  or  costly  accord- 
ing to  the  means  available.  The  doctor's  table 
stands  in  one  corner  of  this  examining  room. 

This  is  not  necessarily  the  last  word  as  to  what 
tuberculosis  dispensaries  should  be,  but  we  have 
found  the  ones  described  practical.  No  tuberculin 
tests  are  given  here,  and  all  sputum  examinations 
are  made  at  the  Health  Department  laboratory. 

Medicines.  A  supply  of  simple  drugs  is  kept 
in  the  medicine  closet.  This  includes  a  few  of  the 
standard  tonics,  such  as  iron,  quinine  and  strych- 


1 88         The  Tuberculosis  Nurse 

nia,  nux  vomica,  gentian  and  alkali,  and  so  forth; 
there  are  also  cough  syrups,  and  heroin,  codeine, 
cascara,  etc.  The  tonics  are  usually  bought  in 
large  quantities,  in  gallon  jugs,  and  in  her  leisure 
moments  the  nurse  pours  them  into  four-  or  six- 
ounce  bottles.  If  these  bottles  are  filled  by  the 
druggist,  the  expense  is  somewhat  greater.  This 
medicine  is  given  free  of  charge,  although  now  and 
then  a  patient  may  wish  to  make  a  small  payment 
of  ten  cents  or  so.  In  themselves,  these  drugs 
cannot  be  said  to  constitute  treatment,  yet  it  has 
been  found  advisable  to  dispense  them.  Patients 
are  so  accustomed  to  being  dosed,  that  they  have 
no  faith  in  an  institution  which  does  not  prescribe 
for  them.  It  is  above  all  things  necessary  to 
make  these  dispensaries  popular,  so  that  patients 
will  freely  seek  them,  and  recommend  them  to 
their  friends.  Only  through  wide  publicity  and 
extensive  patronage  can  they  become  effective 
factors  in  the  fight  against  tuberculosis. 

Hours.  The  hours  at  which  a  dispensary  is  open 
will  depend  somewhat  upon  its  location,  also  upon 
whether  or  not  the  physician's  services  are  volun- 
t  eered ;  in  the  latter  case,  it  will  depend  upon  the 
time  he  is  able  to  give  to  it.  If  it  is  open  in  the 
morning,  the  workingman  cannot  attend  without 
losing  a  whole  day  from  his  work,  nor  are  these 


Consideration  for  Patients         189 

hours  convenient  for  schoolchildren,  or  for  the  busy 
housewife  who  does  most  of  her  work  before  noon. 
If  the  dispensary  is  open  in  the  afternoon,  all  three 
classes  of  patients  may  be  accommodated;  the 
workingman  will  lose  half,  not  an  entire  day, 
while  women  and  children  can  attend  with  no 
inconvenience  at  all.  Afternoon  hours,  say  from 
two  till  five,  not  only  permit  patients  to  be  ex- 
amined by  daylight  instead  of  artificial  light,  but 
the  doctor  will  be  further  aided  in  his  diagnosis 
by  the  presence  or  absence  of  that  characteristic 
symptom,  an  afternoon  temperature.  Night 
clinics  are  necessary  in  certain  localities,  when 
they  may  be  patronized  by  men  and  women, 
employed  during  the  day,  who  would  otherwise 
be  unable  to  come  to  them. I 

Consideration  for  Patients.  The  first  considera- 
tion of  the  dispensary  should  be  the  comfort  and 
welfare  of  the  patients.  We  have  known  many 
dispensaries  where  the  first  consideration  was  the 
experience  of  the  students  or  physicians,  the 
patient  being  regarded  merely  as  good  clinical 
material.  In  dispensaries  connected  with  medical 
schools,  which  are  essentially  used  for  teaching 
purposes,  this  condition  is  unfortunately  necessary, 

1  Night  clinics  are  in  existence  in  New  York,  Hartford,  Boston, 
Chicago,  and  other  cities,  and  are  well  attended. 


190          The  Tuberculosis  Nurse 

yet  we  cannot  believe  that  it  is  necessary  to  the 
extent  to  which  it  is  sometimes  carried.  We  have 
often  known  of  "interesting"  cases  being  held  up 
for  hours,  in  order  that  they  might  be  examined  by 
certain  men,  or  groups  of  students;  moreover,  this 
detention,  prolonged  examination,  and  exposure 
often  took  place  when  the  patient  was  very  weak, 
when  he  lost  his  job  through  the  delay,  or  when  a 
husband's  dinner,  a  nursing  baby,  or  a  houseful 
of  children  made  such  detention  intolerable. 
Patients  often  refuse  to  return  to  a  large  dis- 
pensary on  the  ground  that  "they  keep  you  all 
day,  everyone  in  the  place  examines  you,  and 
you  get  so  tired  and  sick  you  have  to  stay  in  bed 
for  a  week  afterward."  This  lack  of  considera- 
tion— failure  to  look  upon  the  patient  as  a  human 
being — is  what  tends  to  make  dispensaries  unpop- 
ular. We  have  known  patients  to  come  straight 
from  such  an  experience  and  deliver  themselves 
into  the  hands  of  a  quack.  However  necessary 
it  may  be  to  use  certain  dispensaries  as  teaching 
centres,  the  tuberculosis  campaign  demands  clinics 
of  another  kind.  If  the  tuberculosis  dispensary 
is  to  be  a  factor  in  the  fight  against  this  disease, 
it  cannot  afford  to  be  a  training  school  as  well- 
it  should  be  in  charge  of  men  already  trained. 
Function  of  the  Dispensary.  It  follows,  then, 


The  Physician's  Service  191 

that  the  function  of  the  municipal  dispensary  is  of 
necessity  different  from  that  established  for  teach- 
ing purposes.  The  larger  dispensary  serves  a  double 
purpose,  the  little  dispensary  serves  but  one; 
it  is  an  examining  station  for  making  diagnoses. 
Here  the  patient  should  come  as  informally  as  he 
would  to  a  doctor's  office,  and  here  he  should  be 
able  to  consult  experienced  men.  We  feel  that 
the  informality  of  these  little  clinics  constitutes 
their  strong  point.  The  patients  are  not  afraid 
of  them,  and  their  great  advantage  lies  in  their 
social  rather  than  their  scientific  value.  They  are 
merely  places  where  a  communicable  disease  may 
be  discovered  at  the  earliest  possible  moment. 

The  Physician's  Service.  If  a  community 
decides  to  establish  a  dispensary,  the  first  step 
must  be  to  secure  the  services  of  a  physician.  At 
first  this  may  be  voluntary,  and  many  doctors 
will  gladly  offer  an  hour  or  two  of  their  time,  once 
or  twice  a  week.  Should  there  be  great  pressure 
of  work,  it  may  be  possible  to  find  several  men 
willing  to  offer  their  time.  But  however  willingly 
and  freely  offered — for  most  physicians  are 
generous  in  response  to  calls  of  this  sort — it  must 
be  remembered  that,  after  all,  this  service  is  gratuit- 
ous. The  busy  physician  will  often  be  obliged 
to  side-track  his  dispensary  obligations,  in  favour 


192          The  Tuberculosis  Nurse 

of  urgent  private  calls.  This  is  only  to  be  expected, 
yet  too  many  such  side-trackings  are  bad  for  the 
dispensary.  The  patients  lose  confidence  in  it; 
it  is  discouraging  for  a  roomful  of  sick  people  to 
find  no  one  to  receive  them. 

Experience  teaches  us  to  look  askance  at  all 
volunteer  work,  no  matter  how  generously  or 
sincerely  offered.  Under  certain  conditions  it 
may  have  to  be  accepted,  but  whenever  possible, 
the  physician  in  charge  of  the  dispensary  should 
be  paid.  It  is  fairer  to  him,  and  fairer  to  the 
patients. 

The  Health  Department  of  Baltimore  has  three 
special  tuberculosis  dispensaries,  each  open  twice 
a  week,  for  two  hours  at  a  time.  The  physician 
in  charge  is  paid  a  good  salary,  and  as  a  result,  the 
regularity  of  his  attendance  is  in  sharp  contrast 
to  that  in  certain  other  dispensaries,  where  the 
work  is  done  by  well  meaning  but  overworked  men 
who  volunteer  their  services.  Tuberculosis  is  a 
disease  that  cannot  be  overcome  by  volunteer 
work  or  economical  methods. 

The  Physician's  Qualifications.  The  success  of 
the  dispensary  depends  upon  the  ability  and 
character  of  the  physician  in  charge.  He  should 
be  able  to  make  a  diagnosis  by  means  of  ausculta- 
tion and  percussion,  without  hesitating  to  commit 


The  Physician  and  the  Patient    193 

himself  until  a  sputum  examination  reveals  the 
bacilli. J  For  if  finding  the  bacilli  is  to  be  the  sole 
test  by  which  tuberculosis  may  be  recognized,  it 
would  be  possible  for  the  nurse  to  obtain  specimens 
of  sputum  from  her  patients  and  submit  them  to 
the  laboratory  direct — thus  doing  away  with  the 
doctor  and  proving  the  dispensary  superfluous. 

Nor  is  this  all.  The  physician  must  have  a 
strong  social  sense,  and  be  able  to  inspire  his 
patients  with  confidence.  In  no  other  work  does 
the  personal  character  play  so  large  a  part,  and  this 
applies  to  the  doctor  as  well  as  to  the  nurse.  One 
of  our  patients,  enthusiastic  in  her  praise  of  one  of 
the  dispensary  men,  summed  this  up  with  homely 
accuracy:  "He  couldn't  have  been  nicer  to  me 
if  I'd  paid  him  fifty  cents  in  his  office." 

The  Physician  and  the  Patient.  After  the 
patient  has  been  examined,  the  doctor  carefully 
explains  to  him  the  nature  of  his  disease,  and  the 
precautions  necessary.  Since  these  directions 
must  often  be  brief  and  hurried,  he  will  further 
add  that  he  is  sending  a  nurse  to  the  patient's 
home,  to  act  under  his  orders,  and  see  that  certain 
directions  are  carried  out.  In  this  manner,  the 
doctor  prepares  the  way  for  the  nurse's  visit,  and 
gives  her  an  authority  which  greatly  facilitates 

1  See  Chapter  IX.,  page  109. 
13 


194          The  Tuberculosis  Nurse 

her  work.  With  this  assistance,  it  is  far  easier  to 
gain  the  patient's  confidence  than  if  it  has  been 
forgotten  or  withheld.  The  orders  concerning 
the  patient  are  then  given  to  the  nurse,  and  if  these 
include  admission  to  an  institution,  it  is  her  duty 
to  arrange  all  the  necessary  details,  and  so  relieve 
the  physician  of  much  time-consuming  work. 

Duties  of  the  Nurse.  If  a  community  has  a 
special  dispensary  as  well  as  a  special  nurse,  the 
nurse's  duties  are  twofold,  and  should  include 
not  only  the  home  supervision  of  the  patients, 
but  attendance  at  the  dispensary  as  well.  She  is 
the  connecting  link  between  the  two.  In  this 
way,  her  intimate  knowledge  of  home  conditions 
is  placed  at  the  physician's  disposal,  who  is  then 
able  to  give  sounder  advice  and  deal  more  intelli- 
gently with  his  patients  if  he  has  some  knowledge 
of  their  environment. 

The  nurse's  presence  at  the  dispensary  is  often 
a  considerable  assistance  in  persuading  patients 
to  come.  Patients  are  often  frightened  and  shy, 
and  dread  the  unknown,  consequently  it  is  better 
if  the  nurse  can  give  them  the  comforting  assur- 
ance that  she  will  be  on  hand  to  welcome  them. 
From  her  knowledge  of  their  home  conditions,  she 
also  knows  which  cases  can  afford  to  wait,  and 
which  should  be  taken  out  of  turn  and  given  im- 


Duties  of  the  Nurse  195 

mediate  attention.  It  is  thus  possible  to  deal  with 
them  in  a  personal  and  intelligent  manner.  Since 
at  present  the  control  of  tuberculosis  lies  largely 
with  the  patients  themselves,  and  depends  almost 
wholly  upon  their  goodwill  and  co-operation,  it  is 
necessary  to  establish  this  co-operation  as  firmly 
as  possible. 

The  duties  of  the  nurse  consist  in  taking  the 
history  of  the  patient ;  taking  his  weight  and  tem- 
perature, and  preparing  him  for  physical  examina- 
tion. If  the  patient  is  a  woman,  she  must  be 
present  while  this  examination  is  made.  She  also 
gives  such  drugs  as  may  have  been  prescribed. 
On  his  arrival,  each  patient  receives  a  paper 
napkin  to  hold  over  his  mouth  during  coughing 
attacks,  and  to  use  for  expectoration.  A  special 
receptacle  should  be  provided  for  these  soiled 
napkins,  and  they  should  afterwards  be  burned. 
The  nurse  should  come  to  the  dispensary  half 
an  hour  before  it  opens,  in  order  to  put  it  in  readi- 
ness,— to  take  out  the  charts  and  histories,  at- 
tend to  the  drugs,  place  towels  and  sheets  in  the 
examining  rooms,  and  so  forth.  Whenever  the 
clinic  becomes  large  enough  to  require  it,  it  will 
become  necessary  to  place  the  clerical  work  in 
charge  of  a  clerk. 

In  these  informal  clinics  considerable  trouble  is 


196          The  Tuberculosis  Nurse 

often  caused  by  patients  who  arrive  just  before 
closing  time,  and  expect  to  be  examined.  It  is 
unwise  to  encourage  this  sort  of  tardiness,  and  a 
time  limit  should  be  set  and  strictly  adhered  to. 
All  patients  arriving  after  a  specified  hour  should 
be  directed  to  come  another  day,  except  such 
patients  as  are  recognized  by  the  nurse  as  worthy 
of  exception  from  this  rule.  The  most  frequent 
offenders  are  not  the  patients  who  come  from  a 
distance,  but  those  who  live  just  around  the 
corner.  Unless  punctuality  be  insisted  upon, 
there  will  be  endless  overtime  work  for  both  doctor 
and  nurse. 

Tuberculin  Classes.  At  some  of  the  large  dis- 
pensaries, selected  cases  are  formed  into  what  are 
called  Tuberculin  Classes,  and  given  special  treat- 
ment. These  patients  are  very  carefully  chosen, 
both  from  a  financial  as  well  as  a  physical  stand- 
point, and  intensive  work,  of  a  curative  rather 
than  a  preventive  nature,  is  put  upon  them.  The 
treatment  is  carried  out  in  their  homes,  where  as 
nearly  as  possible  sanatorium  conditions  are 
attained.  Unruliness,  or  failure  to  comply  with 
the  regulations,  means  being  dropped  from  the 
class.  These  patients  live  on  a  carefully  planned 
routine,  carried  out  under  close  supervision  of 
both  doctor  and  nurse.  They  report  to  the  dis- 


The  Nurse  in  Home  and  Dispensary  197 

pensary  at  certain  intervals,  once  a  week  or  so, 
and  there  tuberculin  is  administered,  weights 
taken,  and  examinations  made.  Each  patient 
keeps  a  little  book  containing  a  daily  record  of 
his  doings,  including  the  number  of  hours  spent 
in  the  open  air,  food — kind  and  amount,  exercise, 
temperature,  cough,  and  other  symptoms.  This 
book  is  presented  at  each  visit  to  the  dispensary, 
and  the  nurse  also  inspects  it  when  she  visits  his 
home.  These  class  patients  often  do  extremely 
well,  and  excellent  results  are  often  obtained. 
Like  all  work  of  a  curative  nature,  however, — in 
which  the  subjects  are  carefully  selected  and  as 
carefully  rejected, — it  deals  with  so  few  people 
that  it  makes  no  real  impression  on  the  situation. 
The  tuberculosis  problem  is,  what  can  be  done  for 
a  thousand  patients,  not  for  twenty.  It  is  always 
possible  to  select  a  handful  of  cases  and  maintain 
them  indefinitely  at  a  high  level  of  health,  by  a 
considerable  outlay  of  money,  energy,  and  time— 
an  expenditure  from  which  the  community  as  a 
whole  derives  little  benefit. 

To  establish  a  tuberculin  class  is  purely  a  physi- 
cian's affair,  and  all  directions  in  regard  to  it  come 
from  the  doctor  himself. 

The  Nurse  in  Home  and  Dispensary.  When 
the  staff  is  large  and  there  are  several  nurses,  it 


198          The  Tuberculosis  Nurse 

may  seem  advisable,  upon  first  consideration,  to 
assign  one  nurse  solely  to  dispensary  duty,  and 
leave  the  others  to  work  in  the  homes.  It  is  a 
better  plan,  however,  to  let  all  the  nurses  combine 
service  of  both  kinds,  as  the  single  nurse  in  the 
small  community  must  do.  The  intimate  con- 
nection between  home  and  dispensary  should 
never  be  broken — it  is  much  too  valuable.  More- 
over, as  far  as  the  nurse  herself  is  concerned,  the 
monotony  of  dispensary  work  becomes  extremely 
wearing,  and  it  is  well  to  vary  it  with  duty  in  the 
home.  It  is  a  regrettable  fact  that  a  nurse  confined 
to  mere  mechanical  routine,  is  apt  to  lose  that  fine 
understanding  and  sympathy  which  she  needs  in 
her  work,  and  which  is  always  lost  whenever 
human  beings  become  merely  "cases." 

In  Baltimore  this  service  is  arranged  in  the 
following  manner:  There  are  three  Municipal 
Dispensaries,  and  one  other  clinic,  managed  on 
the  same  lines,  although  not  connected  with  the 
Health  Department.  These  are  situated  at  the 
boundary  lines  of  two  or  more  adjoining  districts, 
and  are  thus  accessible  to  the  patients  as  well  as 
the  nurses  of  the  adjacent  areas.  All  four  clinics 
are  served  by  certain  nurses  of  the  Health  Depart- 
ment, who  are  on  duty  on  alternate  days  or  alter- 
nate weeks,  as  the  case  may  be.  Thus,  the  nurse 


The  Nurse  an  Asset  to  Community  199 

from  any  one  district  is  on  dispensary  duty  for  two 
afternoons  a  week,  every  other  week.  This  deprives 
the  home  of  her  services  to  only  a  very  slight  extent 
— a  deprivation  which  is  counter-balanced  by  her 
increased  opportunities  for  effective  work.  We 
should  never  advocate  any  greater  curtailment  of 
home  work,  however,  since  the  home,  or  centre  of 
infection,  is  always  the  chief  point  of  attack. 

From  another  standpoint  it  is  well  that  the 
nurses  combine  both  kinds  of  service.  Through 
sickness  or  other  reasons,  it  may  become  neces- 
sary to  substitute  one  nurse  for  another,  and  it  is 
an  advantage  to  have  nurses  trained  and  able  to 
relieve  each  other  when  necessary. 

The  Nurse  as  an  Asset  to  the  Community.  We 
have  hitherto  considered  the  nurse  as  a  public 
health  nurse,  or  servant  of  the  entire  community. 
Whether  supported  by  public  or  private  funds, 
whether  connected  with  the  Health  Department 
or  a  private  association,  we  have  considered  her 
as  ready  to  answer  all  calls  made  upon  her.  We 
have  regarded  her  as  at  the  service  of  all  physicians, 
dispensaries,  institutions,  social  workers,  and  lay- 
men, ready  to  respond  to  all  calls  without  hesita- 
tion or  discrimination.  Her  unattachment  to  any 
claims  but  those  of  the  community  as  a  whole 
gives  her  this  broad  field. 


200         The  Tuberculosis  Nurse 

If,  however,  her  work  be  limited  to  the  patients 
of  any  one  institution,  association,  or  secc,  she 
is  no  longer  an  asset  to  the  community.  For  ex- 
ample, if  she  is  employed  by  a  certain  dispensary 
to  visit  its  patients  only,  her  work  is  circumscribed. 
Her  usefulness  will  be  restricted — her  service  will 
be  valuable  to  the  physicians  of  such  an  institu- 
tion, and  she  will  collect  data  for  their  records, 
but  her  duties  will  be  localized  for  the  good  of  the 
dispensary,  rather  than  for  society  as  a  whole. 
The  same  would  be  true  if  she  be  employed  by  a 
St.  Vincent  de  Paul  Society  to  care  for  Catholic 
consumptives,  or  by  a  Jewish  organization  to 
follow  up  Jewish  patients — any  arrangement 
through  which  she  visits  one  patient  in  a  block, 
but  refuses  the  case  next  door,  means  a  narrow 
field  of  service.  She  then  becomes  the  nurse  of 
an  institution,  or  a  sect,  rather  than  a  public 
health  nurse.  The  object  of  her  work  is  not  the 
welfare  of  the  community,  but  the  welfare  of  cer- 
tain individual  patients.  Incidentally,  her  work 
may  benefit  the  community,  but  it  falls  far  short 
of  its  possibilities.  It  must  be  supplemented  by 
new  agencies,  with  the  consequent  duplication 
and  waste  of  effort  that  this  always  involves. 

Our  experience  in  Baltimore  will  illustrate  this 
point.     In   1904,  when  tuberculosis   nursing  was 


The  Nurse  an  Asset  to  Community  201 

first  organized,  two  nurses  were  placed  in  the 
field.  One  was  attached  to  the  dispensary  of 
the  Johns  Hopkins  Hospital,  the  other  placed  in 
charge  of  the  Visiting  Nurse  Association.  Be- 
tween them  the  city  was  divided  into  halves,  one 
nurse  working  in  the  eastern,  the  other  in  the 
western  portion  of  the  town.  The  dispensary 
nurse  visited  only  patients  who  had  been  to  the 
dispensary.  The  nurse  of  the  Visiting  Nurse 
Association  visited  not  only  dispensary  cases,  but 
all  patients  reported  from  whatever  source.  Thus, 
in  East  Baltimore,  if  two  consumptives  lived  in 
the  same  tenement,  one  a  dispensary  case  and  the 
other  under  no  supervision  at  all,  only  one  of  these 
two  was  visited.  In  West  Baltimore,  both  patients 
were  cared  for  on  equal  terms.  At  the  end  of  a 
year,  another  nurse  was  added  to  the  Visiting 
Nurse  Association  staff,  but  not  to  the  dispensary. 
The  city  was  then  redivided,  this  time  into  thirds, 
and  again  the  patients  were  cared  for  under  the 
same  conditions.  The  dispensary  nurse  served 
the  Johns  Hopkins  Dispensary;  the  Visiting 
Nurses  served  the  dispensary  and  the  community 
as  well.  Finally,  in  1910,  the  tuberculosis  work 
of  the  Visiting  Nurse  Association  was  taken  over 
by  the  city,  thus  creating  a  new  municipal  depart- 
ment, the  Tuberculosis  Division  of  the  City 


2O2          The  Tuberculosis  Nurse 

Health  Department.  At  that  time  the  dispensary 
nurse  gave  up  visiting  in  the  homes  of  the  patients, 
and  confined  herself  entirely  to  routine  dispensary 
duties.  This  left  all  visiting  work  to  the  Health 
Department  nurses,  who  were  as  punctilious  in 
making  reports  to  the  dispensary  as  was  the 
dispensary  nurse  herself.  By  this  arrangement, 
the  Phipps,  in  common  with  every  other  dis- 
pensary in  the  city,  has  had  a  large  staff  of  nurses 
placed  at  its  disposal.  Both  the  dispensaries  and 
the  community  gain  through  this  co-operation. 


CHAPTER  XV 

The  Nurse  in  Relation  to  the  Institution — Reports  Made  to  the 
Institution — Procuring  Patients  for  it — The  Value  of  the 
Sanatorium — Sanatorium  Outfit — Return  from  the  Sana- 
torium— Work  for  the  Arrested  Case — Light  Work — Out- 
door Work. 

The  Nurse  in  Relation  to  the  Institution.     As 

the  nurse  is  the  go-between  from  patient  to  physi- 
cian, and  from  patient  to  dispensary,  so  also  does 
her  service  link  together  patient  and  institution. 
This,  of  course,  is  only  possible  if  she  is  a  public 
health  nurse — not  if  she  is  the  agent  for  one  in- 
stitution alone,  or  if  she  is  employed  to  serve 
one  set  of  people  instead  of  the  community  as  a 
whole.  Just  as  she  should  be  at  the  service  of 
every  physician,  dispensary,  and  layman  who 
chooses  to  call  upon  her,  so  in  like  manner  should 
she  serve  both  hospital  and  sanatorium.  She  will 
act  as  beater-up  in  the  matter  of  sending  patients 
into  these  institutions;  will  arrange  all  details  con- 
nected with  their  admission,  and  finally,  upon  their 
discharge,  will  take  them  again  under  her  super- 
vision and  care.  By  this  co-operation,  the  patient 

203 


204          The  Tuberculosis  Nurse 

himself  profits,  likewise  the  community,  while  the 
institutions  are  enabled  to  keep  in  touch  with 
their  discharged  cases,  learn  of  their  condition, 
and,  through  the  nurse's  reports,  add  to  their 
histories  and  records  from  time  to  time  in  a  wray 
which  will  greatly  enhance  their  value. 

There  is  complete  co-operation  between  the 
various  institutions  of  Baltimore  and  the  nurses 
of  the  Health  Department.  Of  the  five  institu- 
tions near  the  city,  four  admit  both  early  and  late 
cases,  while  one  is  for  advanced  cases  only.  When- 
ever a  patient  is  admitted  to  or  discharged  from 
one  of  these  institutions,  either  hospital  or  sana- 
torium, the  Health  Department  is  at  once  notified 
of  the  fact.  Following  admission,  the  nurse 
visits  the  home  and  arranges  for  the  fumigation. 
Two  thirds  of  the  patients  admitted  are  already 
known  and  under  supervision,  but  whether  known 
or  unknown,  the  visit  is  made  and  fumigation 
arranged  for  in  the  usual  manner.  In  homes  where 
the  •  patient  is  unknown,  the  nurse  often  finds 
suspicious  cases,  which  she  sends  for  examination 
and  diagnosis.  By  means  of  this  sharp  look-out 
the  visiting  list  is  considerably  augmented. 

When  the  discharge  of  a  case  is  reported,  the 
patient  may  or  may  not  have  been  under  previous 
supervision.  If  already  on  the  visiting  list,  the 


Reports  Made  to  the  Institution   205 

nurse  merely  resumes  her  visits.  If  not  on  the  list, 
he  is  taken  on  at  once.  Needless  to  say,  the 
physician  in  charge  of  the  institution  should  pre- 
pare the  way  for  the  nurse's  coming,  as  should  the 
physician  of  the  dispensary.  If  he  forgets  to  do 
so,  the  nurse  may  have  some  difficulty,  especially 
with  patients  discharged  in  good  condition,  who 
see  no  need  for  her  services.  When  discharged 
in  bad  condition,  the  reason  is  obvious  enough, 
but  in  either  case  co-operation  with  the  institution 
is  necessary. 

Reports  Made  to  the  Institution.  The  reports 
made  to  the  institution  vary  in  accordance  with 
the  wishes  of  the  physician  in  charge.  Sometimes 
they  are  informal,  made  on  certain  specified  cases ; 
sometimes  they  are  extensive  and  deal  with  large 
numbers  of  individuals.  The  value  of  these 
reports  is  indicated  by  the  following  examples: 
Two  months  ago  a  young  girl  was  admitted  as  a 
paying  patient,  but  she  is  now  at  the  end  of  her 
resources,  which  consisted  of  a  small  fund  sub- 
scribed through  contributions  of  her  fellow  work- 
ers. If  she  is  to  remain  longer  at  the  sanatorium, 
she  must  be  transferred  to  the  free  list.  Or  we  find 
that  a  young  man,  admitted  erroneously  to  the 
free  list,  is  in  a  position  to  pay;  in  justice  to  the 
institution  and  those  who  perforce  must  accept 


206          The  Tuberculosis  Nurse 

its  hospitality,  this  patient  should  be  transferred 
to  the  paying  side.  Or  we  receive  a  letter  from 
the  superintendent,  saying  that  a  certain  patient 
has  failed  to  arrive  on  the  day  specified,  and  asking 
us  to  look  into  the  matter.  Upon  investigation 
we  may  find  that  a  death  in  the  family,  an  accident, 
or  the  lack  of  railway  fare  has  been  the  cause  of 
his  non-arrival.  Provision  for  him  to  go  can  then 
be  made — his  place  is  not  forfeited,  but  held  for 
him  until  a  more  favourable  time.  These  personal 
relations  between  the  nurse  and  the  institution 
bring  a  great  sense  of  cordial  understanding  and 
mutual  good-will. 

The  more  extensive  reports  are  managed  as 
follows:  Once  a  year,  or  oftener  if  necessary, 
certain  institutions  send  to  the  Health  Depart- 
ment a  full  list  of  their  discharged  patients,  whom 
they  wish  looked  up.  The  names  and  addresses 
are  written  on  separate  slips  of  paper,  which 
contain  a  printed  list  of  questions  to  be  answered. 
These  are  distributed  among  the  nurses  of  the 
different  districts,  each  nurse  being  responsible 
for  the  patients  in  her  own  territory.  Within  a 
week  or  ten  days  all  the  slips  are  filled  in,  and  a 
full  return  made  on  all  cases  submitted  for  in- 
vestigation. This  involves  little  extra  work  on  the 
part  of  the  nurses,  since  in  nearly  every  instance 


Procuring  Patients  for  the  Institution  207 

the  patients  are  already  under  supervision — and 
if  through  any  oversight  they  are  not,  it  affords 
a  means  of  finding  them.  The  superintendents 
of  the  various  institutions  find  this  a  satisfactory 
way  of  keeping  in  touch  with  their  ex-patients, 
and  we  think  that  this  work  is  well  within  the  field 
of  the  visiting  nurse.  Each  gains  by  this  co-opera- 
tion— the  Health  Department,  which  wishes  to 
supervise  all  consumptive  patients,  and  the  institu- 
tion, which  wishes  accurate  data  for  its  reports. 
In  effective  social  work  the  keynote  of  success  is 
reciprocity. 

Procuring  Patients  for  the  Institution.  In  still 
another  way  does  the  nurse  serve  the  institution 
and  that  is  by  procuring  patients  for  it.  Large, 
well  organized,  and  well  equipped  institutions  have 
little  difficulty  in  filling  their  beds,  but  this  is  often 
the  reverse  with  those  less  known  and  less  attrac- 
tive. It  takes  much  persuasion  to  induce  a  sick 
man  to  leave  his  home,  and  it  often  takes  still  more 
to  persuade  his  family  to  let  him  go.  To  point 
out  the  necessity  for  institutional  care,  and  induce 
the  patient  to  take  advantage  of  this,  is  the  chief 
duty  of  the  public  health  nurse.  Only  when  she 
does  this  duty  thoroughly  and  well  does  the 
demand  for  hospital  beds  exceed  the  supply. 
For  example:  in  Baltimore,  before  the  nurses  went 


208          The  Tuberculosis  Nurse 

on  duty,  the  large  hospital  for  advanced  cases 
was  never  more  than  half  full.  The  community 
was  not  well  enough  educated  to  take  advantage 
of  it.  Since  the  nurses  have  been  on  duty,  how- 
ever, not  only  has  this  hospital  been  filled  to 
capacity,  but  the  capacity  itself  has  been  enlarged 
to  nearly  double — while  a  long  waiting  list  is 
constantly  maintained.  A  small  sanatorium  was 
recently  opened  in  Maryland,  with  a  capacity  of 
twenty  beds ;  at  the  end  of  five  months,  it  had  only 
five  patients.  The  nurses'  aid  was  solicited,  and 
within  a  week  it  was  full.  This  situation  has 
also  occurred  in  other  cities,  which  found  them- 
selves equipped  with  excellent  hospital  accommo- 
dations, which  the  patients  refused  to  make  use  of. 
Co-operation  between  the  institution  and  the 
municipal  or  visiting  nurses  would  doubtless  have 
promptly  remedied  this  state  of  affairs.  Inci- 
dentally we  may  observe,  the  better  managed 
and  more  comfortable  the  institution,  the  less 
difficulty  there  is  in  keeping  it  full.  It  must  offer 
substantial  advantages  over  the  home — attractions 
which  even  the  most  ignorant  and  prejudiced  must 
be  trained  to  appreciate. 

The  Value  of  the  Sanatorium.  The  sanatorium 
for  the  treatment  of  hopeful  cases  is  by  no  means 
as  valuable  as  was  at  first  expected.  The  cure 


The  Value  of  the  Sanatorium     209 

of  tuberculosis  is  at  best  very  problematical,  and 
the  sanatorium  is  chiefly  useful  to  those  who  can 
control  their  environment  upon  discharge.  Un- 
less this  can  be  done,  treatment  will  be  of  little 
avail,  although  it  will  delay  the  inevitable  end. 
The  patient  who  comes  from  the  alley  and  returns 
to  the  alley  is  foredoomed.  And  as  most  patients 
come  from  the  alley,  figuratively  speaking,  and  are 
afterwards  obliged  to  return  to  it,  the  results  ob- 
tained by  these  sanatoriums  are  by  no  means  com- 
mensurate with  the  expense  involved  in  maintaining 
them.  Whatever  benefit  is  derived  from  them  is  for 
the  individual,  rather  than  for  the  community. 

In  the  tuberculosis  campaign,  the  sanatorium 
occupies  a  place  of  secondary  importance.  We 
could  fight  quite  as  successfully  without  it— 
possibly  better,  since  the  money  devoted  to  the 
upkeep  of  these  very  costly  institutions  could 
then  be  diverted  to  more  radical  purposes.  How- 
ever, the  sanatorium  exists,  and  every  patient 
should  be  given  his  individual  opportunity.  It 
is  usually  more  difficult  to  get  a  patient  into  a 
sanatorium  than  into  a  hospital.  The  former  is  for 
early  or  moderately  advanced  cases,  who  have  a 
reasonable  chance  of  improvement,  therefore  it 
would  seem  a  simple  matter  to  induce  them  to  go. 

Yet  to  persuade  a  patient  that  he  needs  such 
14 


210          The  Tuberculosis  Nurse 

treatment,  especially  when  he  feels  well  and  has 
few  symptoms,  is  often  a  difficult  task.  The 
peculiar  psychology  of  the  consumptive,  his 
optimism  and  refusal  to  believe  that  he  has 
tuberculosis,  is  as  well  marked  in  the  early  as  in 
the  later  stages  of  the  disease.  On  the  other  hand, 
the  difficulty  is  often  of  an  economic  nature. 
When  the  patient  stops  work,  his  income  ceases, 
and  this  often  determines  his  refusal.  This  is  why 
many  patients  work  until  they  drop  in  harness. 
Through  the  Charity  Organization,  or  other 
similar  agencies,  it  is  possible  to  solicit  aid  for  a 
certain  number  of  these  cases,  and  this  must 
always  be  done.  Such  relief,  however,  is  very 
uncertain,  and  latent  periods  of  considerable 
duration  often  intervene  between  the  time  it  is 
asked  for  and  such  time  as  it  may  be  given.  Even 
when  given,  it  very  seldom  approximates  the 
wages  that  the  patient  himself  has  been  able  to 
earn.  Thus,  a  patient  earns  twenty  dollars  a 
week ;  with  luck,  we  may  obtain  for  his  family  an 
income  of  eight  or  ten.  This  is  no  reflection  upon 
the  Charity  Organization  Society,  which  has 
probably  pulled  every  conceivable  wire  in  order  to 
raise  even  that  amount — but  it  explains  why  the 
patient  refuses  the  sanatorium  and  hangs  on  to  his 
job  until  he  can  work  no  longer. 


Sanatorium  Outfit  211 

In  many  cases  on  the  other  hand,  there  is  no 
question  of  poverty  to  contend  with — neither  the 
wage-earner's  reluctance  to  stop  work,  nor  the 
mother's  unwillingness  to  leave  a  houseful  of  little 
children.  Instead,  we  must  contend  with  ignor- 
ance, prejudice,  and  mental  inertia — a  moral 
alley  quite  as  dark  as  that  of  the  slum.  One  of  the 
most  discouraging  features  of  this  work  is  having 
to  stand  by  and  see  the  patient  throw  away  his 
chances.  Tuberculosis  waits  for  no  one,  and  it 
requires  not  only  physical,  but  mental  and  moral 
strength  to  resist  it.  Before  we  can  remake  and 
reconstruct  a  supine  individual,  the  disease  wins 
out  in  the  race. 

There  is  one  consolation,  however;  hopeful 
cases  are  usually  far  less  dangerous  than  advanced 
ones.  The  refusal  of  sanatorium  treatment  is  a 
loss  to  the  individual  only.  Furthermore,  we  have 
this  grim  solace — when  they  finally  consent  to  go, 
after  weeks  and  months  of  delay,  they  do  so,  too 
late  to  help  themselves,  it  is  true,  but  at  a  time 
when  they  are  most  dangerous  to  other  people. 

Sanatorium  Outfit.  When  a  patient  enters  a 
sanatorium,  the  nurse  must  see  that  he  is  supplied 
with  clothing  heavy  and  warm  enough  for  outdoor 
living.  If  he  has  money,  he  should  be  instructed 
what  to  buy.  If  he  has  none,  these  things  must 


212          The  Tuberculosis  Nurse 

then  be  procured  through  some  charitable  associa- 
tion. No  patient  should  be  permitted  to  enter  a 
sanatorium  unless  properly  equipped,  and  fre- 
quently his  decision  against  going  is  due  to  lack  of 
such  equipment. 

In  winter,  he  naturally  requires  much  more 
than  in  summer.  Roughly  speaking,  his  ward- 
robe should  contain  at  least  two  changes  of  flannel 
underclothing,  a  sweater,  overcoat,  woollen  cap, 
woollen  gloves,  overshoes,  flannel  night  clothing, 
a  dressing-gown,  toilet  articles,  and  a  hot-water 
bottle.  Some  institutions  have  a  printed  list  of 
the  articles  required,  which  is  sent  to  the  patient 
when  his  application  is  accepted.  A  steamer  rug 
is  usually  necessary,  a  cheap  substitute  for  which 
may  be  found  in  the  large  horse-blanket,  sold  in 
saddlery  shops. 

Return  from  the  Sanatorium.  When  a  patient 
returns  from  a  sojourn  in  an  institution,  he  may  or 
may  not  be  better,  but  he  has  certainly  received 
a  liberal  education  in  what  to  do,  and  how  to  take 
care  of  himself.  Often,  however,  he  is  totally 
unable  to  apply  this  knowledge,  or  to  adapt  his 
home  environment  to  his  needs.  So  carefully  is 
the  institutional  life  planned,  and  so  smoothly 
does  he  fit  into  it,  that  he  has  no  conception  of  the 
time  and  thought  that  have  gone  into  this  planning. 


Work  for  the  Arrested  Case      213 

When  he  comes  home,  he  knows  theoretically  what 
to  do,  but  in  comparison  with  the  institution  his 
home  surroundings  seem  so  poor  and  so  inade- 
quate, that  he  becomes  hopelessly  bewildered  and 
confused.  It  is  at  this  point  that  the  nurse  has  her 
great  opportunity.  She  teaches  him  to  apply 
what  he  has  learned,  and  how  he  may  approximate 
sanatorium  conditions  and  routine.  She  goes  to 
work  much  as  she  does  upon  her  first  visit  to  the 
home,  but  this  time  she  is  working  in  a  soil  already 
ploughed.  The  patient  himself  may  be  almost  as 
helpless,  but  he  will  follow  suggestions,  and  co- 
operate with  an  intelligent  enthusiasm  gained 
through  his  sanatorium  education. 

Work  for  the  Arrested  Case.  When  a  patient 
returns  from  the  sanatorium  able  to  work,  the 
question  of  employment  is  a  serious  one.  Our 
experience  has  been  that  of  Dr.  Lyman : x  as  a 
rule,  unless  if  is  an  exceedingly  injurious  employ- 
ment, it  is  better  to  let  him  return  to  his  former 
occupation  than  to  seek  a  new  one.  He  under- 
stands his  old  work,  and  for  this  reason  it  will 
be  easier  for  him  than  one  to  which  he  is  unac- 
customed. The  difficulty  of  finding  suitable  em- 
ployment for  arrested  cases,  and  the  number  of 
relapses  that  occur  in  consequence,  serve  once 

1  Dr.  David  R.  Lyman,  Wallingford,  Connecticut. 


214          The  Tuberculosis  Nurse 

more  to  emphasize  the  value  of  prevention  rather 
than  cure. 

There  is  one  point  which  must  always  be  brought 
out.  It  is  not  so  much  what  the  patient  does  with 
his  working  hours,  as  what  he  does  with  his  leisure 
hours,  which  determines  his  ability  to  hold  his 
own.  An  arrested  case  may  work  eight  or  ten 
hours  a  day,  in  office,  factory,  or  shop,  and  still 
remain  well,  provided  he  spends  the  remaining 
hours  of  the  twenty-four  in  a  proper  manner. 
The  ex-sanatorium  case,  rejoicing  in  his  apparently 
restored  health  and  in  his  regained  liberty,  feels 
that  he  can  resume  life  on  exactly  the  same  terms 
as  before.  This  he  can  never  do.  He  has  tuber- 
culosis, and  he  always  will  have  tuberculosis, 
although  it  may  be  latent  at  the  moment.  The 
fact  that  it  is  quiescent  does  not  mean  that  it  will 
not  light  up  again  at  the  slightest  indiscretion. 
He  must  bear  this  fact  constantly  in  mind  and 
order  his  life  accordingly.  If  he  expects  to  work 
and  remain  well,  he  cannot  burn  the  candle  at 
both  ends,  even  in  the  mildest  manner.  He  must 
forego  late  hours,  moving  picture  shows,  pool- 
rooms, saloons,  dance-halls — everything,  no  mat- 
ter how  harmless  in  itself,  which  places  an  extra 
strain  upon  his  vitality.  At  the  end  of  the 
day's  work  he  should  rest  quietly,  preferably  in 


Light  Work  215 

the  open  air.  Eight  or  ten  hours'  sleep  at  night  is 
a  necessity.  The  most  critical  time  in  a  patient's 
career  is  that  which  follows  his  return  from  a 
sanatorium,  and  it  is  at  this  particular  moment 
that  the  nurse's  supervision  and  encouragement 
are  so  greatly  needed. 

Light  Work.  Many  patients  return  from  the  san- 
atorium, unable  to  work  at  their  former  occupation, 
yet  sufficiently  strong  to  do  "light  work, "  if  such  a 
thing  can  be  found.  In  my  experience,  suitable 
"light  work"  for  these  cases  has  yet  to  be  discov- 
ered. We  all  know  of  patients  who  have  been  given 
easy  positions  as  night  watchmen,  elevator-men, 
corridor-men,  office  work,  gardening,  and  so  forth, 
and  who  have  done  well  at  such  employment. 
The  number  of  such  positions,  however,  is  so  small 
and  so  out  of  proportion  to  the  number  of  those 
who  seek  such  occupation  that  it  forms  no  adequate 
answer  to  the  question;  what  light  work  can  we 
find  for  the  arrested  case?  Our  present  industrial 
system,  which  produces  the  class  of  people  from 
which  the  consumptive  is  so  largely  recruited,  also 
fails  to  provide  proper  employment  for  him  after 
his  so-called  recovery.  The  pressure  of  this  system 
makes  it  sufficiently  difficult  for  an  able-bodied 
man  or  woman  to  find  work  that  pays,  or  even  any 
work  at  all,  but  to  find  such  work  for  the  handi- 


216          The  Tuberculosis  Nurse 

capped  is  almost  impossible.  Light  work  means 
light  pay,  and  light  pay  means  an  insufficiency  of 
food,  clothing,  and  shelter,  all  three  of  which  are 
needed  for  the  maintenance  of  health.  In  these 
days  when  the  physically  fit  cannot  always  earn 
a  living  wage,  what  chance  has  the  poor  con- 
sumptive? 

Outdoor  Work.  Another  favourite  fallacy  is 
the  advantage  of  outdoor  work  for  the  returned 
patient.  The  sole  value  of  outdoor  work  lies  in 
the  opportunity  to  breathe  fresh  air,  but  this 
benefit  may  be  more  than  offset  by  the  strain  of 
long  hours,  exposure  to  heat,  cold,  and  rain,  the 
lifting  of  heavy  weights,  and  so  forth.  All  these 
objections  apply  to  farm-wrork,  driving  delivery 
or  freight  waggons,  the  occupation  of  motorman, 
conductor,  and  so  forth.  Now  and  then,  patients 
undertake  work  of  this  character  and  do  well  at 
it,  but  we  cannot  but  believe  that  this  is  in  spite, 
of,  rather  than  because  of,  their  occupation. 

In  summing  up  the  nurse's  value  to  these  dis- 
charged cases,  we  find  her  able  to  give  immense 
assistance  at  a  most  crucial  period  in  the  patient's 
life.  By  this  help  and  advice,  she  can  often  pre- 
vent his  relapse,  or  at  least  delay  it  for  a  long  time. 
Her  supervision  provides  incentive  and  encourage- 
ment, and  her  careful  watchfulness,  both  of  the 


Outdoor  Work  217 

patient  and  his  household,  is  of  value  in  detecting 
further  danger  signals.  If,  as  too  often  happens, 
he  is  eventually  swept  under  by  currents  too 
strong  for  him,  she  is  still  on  the  spot,  tried 
counsellor  and  friend,  to  make  safer  and  easier  the 
downward  path. 


CHAPTER  XVI 

Hospitals  for  Advanced  Cases — The  Careful  Consumptive — 
Chief  Duty  of  the  Nurse — Responsibility  of  the  Institution 
— Home  Care  of  the  Advanced  Case — Exceptions  to  Insti- 
tutional Care — Compulsory  Segregation. 

Hospitals  for  the  Advanced  Case.  The  crux 
of  the  tuberculosis  problem  lies  in  the  segregation 
of  the  advanced  case.  Until  the  distributor  is 
removed  from  his  family,  and  separated  from  the 
intimate  circle  surrounding  him,  we  can  make  but 
little  progress  in  the  fight  against  this  disease. 
No  community  can  protect  itself  from  the  ravages 
of  tuberculosis  until  it  provides  a  place  to  which 
these  advanced  cases  may  be  sent.  Not  only  do 
we  need  large  special  hospitals  for  these  patients, 
but  we  need  special  wards  for  consumptives  in 
connection  with  every  general  hospital  which 
receives  either  city  or  State  appropriations.  These 
special  wards  would  be  of  even  greater  benefit 
to  the  community  than  large  special  hospitals 
situated  in  the  environs  of  a  city,  since  it  would 
be  easier  to  persuade  a  patient  to  enter  an  institu- 
tion just  "round  the  corner"  than  to  go  to  one  far 

218 


Hospitals  for  the  Advanced  Case  219 

distant  from  his  home.  A  dying  man  dreads 
being  separated  from  his  family,  and  his  family  is 
equally  reluctant  to  part  from  him;  furthermore, 
if  a  hospital  is  remote  from  the  city,  his  family  can 
afford  neither  time  nor  carfare  for  frequent  visits. 
These  facts  play  an  important  part  in  influencing 
a  patient's  decision,  and  due  consideration  should 
be  accorded  them. 

It  would  probably  cost  less  to  build  and  main- 
tain special  wards  in  connection  with  hospitals 
already  existing  than  to  erect  and  support  an 
entirely  new  institution.  The  greatest  objection 
to  special  wards  is  that  the  coughing  of  the  con- 
sumptives is  disturbing  to  the  other  patients,  but 
if  the  ward  is  sufficiently  isolated  (a  separate 
building,  if  the  hospital  is  planned  on  the  cottage 
system)  this  objection  would  not  apply.  Further- 
more, these  wards  would  offer  good  teaching  cen- 
tres, where  both  doctors  and  nurses  could  learn 
more  about  pulmonary  tuberculosis  than  the 
average  hospital  teaches  to-day. 

In  attempting  to  secure  ground  for  the  erection 
of  a  tuberculosis  hospital,  there  is  usually  great 
opposition  from  laymen.  They  are  not  only 
afraid  of  tuberculosis,  but  they  fear  the  deprecia- 
tion of  property  which  may  arise  in  the  vicinity 
of  such  an  institution.  Considerable  education 


220          The  Tuberculosis  Nurse 

is  required  to  calm  them  to  a  realization  that 
the  consumptive  sheltered  and  cared  for  is  less 
dangerous  than  the  consumptive  at  large  and  un- 
recognized. When  it  comes  to  a  special  ward  in 
connection  with  a  city  hospital,  we  may  again  en- 
counter great  opposition,  really  from  the  same  rea- 
son, though  the  objections  expressed  are  expense  of 
such  a  ward,  the  lack  of  nursing  facilities,  that  the 
room  is  needed  for  acute  diseases,  and  so  on.  All 
of  which  is  a  grave  commentary,  from  the  people 
who  best  understand  it,  upon  the  infectious  nature 
of  this  disease.  Yet  the  medical  profession  tells 
us  with  apparent  sincerity  that  "the  careful  con- 
sumptive is  not  a  menace."  If  this  be  true,  where 
can  he  be  more  careful  and  less  of  a  menace  than 
in  a  place  specially  provided  for  him? 

The  truth  of  the  matter  is,  there  is  not,  nor  can 
there  be,  a  careful  enough  consumptive.  The 
very  nature  of  the  disease  precludes  such  a  possi- 
bility, however  much  we  educate  him,  or  however 
earnestly  he  himself  may  try  to  co-operate  to  that 
end.  And  for  the  vast  majority  of  patients,  from 
whom  we  can  obtain  but  little  or  only  spasmodic 
co-operation,  there  is  even  less  to  be  said.  There 
is  one  simple  method  of  determining  whether  or 
not  a  patient  is  careful — it  consists  in  asking  the 
question:  Under  these  circumstances,  would  I, 


Hospitals  for  the  Advanced  Case  221 

myself,  feel  safe?  Would  I  be  satisfied  as  to  the 
safety  of  my  nearest  and  dearest  friend? 

At  the  beginning  of  the  year  1912,  the  nurses  of 
the  Tuberculosis  Division  of  Baltimore  had  on  their 
visiting  lists  about  2800  patients.  Of  these  2020 
were  positively  diagnosed,  and  had  been  under  sup- 
ervision for  over  three  months .  Undiagnosed  cases , 
and  positive  ones  who  had  been  under  supervision 
less  than  three  months  were  excluded.  These  2020 
cases  were  then  classified  according  to  their  willing- 
ness or  ability  to  follow  instructions,  the  groups  be- 
ing :  Fairly  Careful,  Careless,  and  Grossly  Careless. 
We  purposely  omitted  a  "Careful "  class,  since  ade- 
quate carefulness  would  imply  a  condition  in  which 
there  was  absolutely  no  danger,  a  condition  hardly 
possible  with  this  disease.  In  Fairly  Careful  we 
included  all  those  patients  who  really  tried  to 
follow  advice,  doing  so  to  the  best  of  their  ability. 
Careless  included  those  who  tried  intermittently, 
or  who  were  badly  hampered  by  circumstances. 
Grossly  Careless  speaks  for  itself. 

The  results  of  this  analysis  are  here  given: 

Patients  visited  over  three  months 194 

Fairly  Careful 98,  or  50.5% 

Careless 75,  or  38.65% 

Grossly  Careless 21,  or  10.82% 


222          The  Tuberculosis  Nurse 

Patients  visited  over  six  months 346 

Fairly  Careful 171,  or  49.43% 

Careless 151,  or  43.64% 

Grossly  Careless 24,  or    6.84% 

Patients  visited  over  one  year 623 

Fairly  Careful 300,  or  48.15% 

Careless 267,  or  42.85% 

Grossly  Careless 56,  or    8.98% 

Patients  visited  over  two  years 857 

Fairly  Careful 443,  or  51.69% 

Careless 339,  or  39-55% 

Grossly  Careless 75,  or    8.75% 

Total  Number  of  Patients 2020 

Fairly  Careful 1012,  or  50.09% 

Careless 832,  or  41.13% 

Grossly  Careless 176,  or     8% 

It  will  be  noticed  that  these  percentages  vary 
but  slightly,  or  to  a  negligible  extent.  Roughly 
speaking,  about  half  the  patients  try  to  be  careful, 
and  half  do  not  try,  or  do  not  succeed  if  they 
attempt  it.  Furthermore,  it  will  be  noticed  that 
the  time  element  has  little  to  do  with  making  a 
patient  careful.  The  natural  supposition  would  be 
that  a  patient  visited  for  one  or  two  years  would 
show  a  marked  increase  of  carefulness  over  those 


Hospitals  for  the  Advanced  Case  223 

who  had  been  under  supervision  but  a  few  months. 
Yet  there  is  virtually  no  difference  between  them, 
50.5%  of  the  three-months  class  being  care- 
ful, as  against  51.69  %  of  the  two-years  class. 
These  figures,  we  believe,  show  conclusively  that 
long-continued  teaching  does  not  necessarily  lead 
to  satisfactory  results.  They  also  show  that  the 
patient  left  in  his  own  home,  even  under  constant 
supervision,  is  unable  to  achieve  a  degree  of 
technique  which  means  positive  protection  to  those 
around  him.  There  is  but  one  conclusion  to  be 
drawn  from  these  facts — not  that  the  nurse  is 
useless,  but  that  the  patient  at  large  is  dangerous. 
It  proves  the  necessity  for  hospital  care. 

The  hospital  for  a  patient  to  die  in  appeals  less 
to  public  sympathy  than  as  a  place  in  which  he 
may  get  well.  But  it  is  better  economy.  Care 
of  the  open  case,  during  his  last  and  most  infectious 
stages,  is  care  which  strikes  at  the  very  root  of  the 
evil.  Until  this  fact  is  realized  and  full  provision 
made  for  these  cases,  it  will  be  a  waste  of  time  and 
money  to  spend  them  on  superficial  or  half-way 
measures.  If  our  goal  is  the  elimination  of  tuber- 
culosis, we  should  concentrate  our  efforts  upon 
radical  and  fundamental  methods. 

At  present,  however,  we  can  conceive  of  no 
community  sufficiently  advanced  or  far-seeing  to 


224          The  Tuberculosis  Nurse 

make  adequate  provision  for  these  last-stage 
cases.  Therefore,  the  patients  who  make  up  the 
difference  between  the  number  of  those  needing 
hospital  care,  and  those  receiving  hospital  care, 
must  be  cared  for  in  their  homes  by  the  nurse. 
Never  for  a  moment  should  home  supervision  be 
considered  a  satisfactory  substitute  for  hospital 
accommodation.  The  nurse's  efforts,  no  matter 
how  thorough  and  conscientious,  can  never  en- 
tirely remove  the  danger.  Her  care  often  lessens 
it  to  a  marked  degree,  but  never  absolutely  elimi- 
nates it.  It  is  at  best  a  makeshift,  a  stopgap — • 
better  than  nothing,  often  much  better  than 
nothing,  but  never  for  a  moment  the  proper 
alternative  to  removing  the  patient  from  his  home. 
No  one  knows  better  than  the  nurse  herself  the 
inadequacy,  the  futility,  of  even  the  closest  super- 
vision. 

Chief  Duty  of  the  Nurse.  For  this  reason,  the 
chief,  the  absolutely  most  important  duty  of  the 
nurse  is  to  induce  the  infectious  patient  to  go  from 
his  home  into  an  institution.  To  accomplish 
this  end,  she  must  bring  every  effort  to  bear 
upon  the  patient  and  his  family,  and  appeal  to 
them  from  every  conceivable  angle.  This  is  her 
one  great  duty — the  paramount  reason  for  her 
existence. 


Home  Care  of  the  Advanced  Case  225 

To  accomplish  this,  is  as  difficult  as  it  is  import- 
ant. A  patient  does  not  willingly  give  up  h*is 
home,  however  poor  and  humble  it  may  be,  while 
his  family  often  cling  to  him  with  an  obstinacy 
open  to  no  argument.  As  a  rule,  the  difficulty 
of  removing  him  is  in  inverse  ratio  to  his  intelli- 
gence, and  to  the  danger  to  those  surrounding 
him. 

Responsibility  of  the  Institution.  In  overcom- 
ing this  prejudice,  a  great  deal  depends  upon  the 
character  of  the  institution  itself.  It  is  not  enough 
to  establish  hospitals — they  must  be  attractive 
and  comfortable  to  such  a  degree  that  they  become 
highly  desirable  to  prospective  patients.  They 
must  be  well  run,  well  managed,  the  food  must 
be  good,  and  the  patients  well  treated.  To  obtain 
segregation,  we  must  have  hospitals  which  offer 
great  advantages  over  the  home. 

Home  Care  of  the  Advanced  Case.  If  there  are 
no  hospital  facilities,  it  then  becomes  the  nurse's 
duty  to  give  nursing  care  to  the  bed-ridden  patient. 
This  is  also  done  when  the  hospital  accommoda- 
tions are  limited,  and  the  patient  must  wait  to  be 
admitted.  During  this  waiting  period,  which 
may  extend  over  weeks,  he  should  be  visited  every 
day  (or  at  least  as  often  as  the  work  will  permit), 

and  given  such  care  as  he  requires,  including  bed- 
is 


226          The  Tuberculosis  Nurse 

baths,  care  of  the  back,  and  so  forth.  The  nurse 
must  also  teach  some  older,  responsible  member  of 
the  family  how  to  care  for  him  in  the  intervals 
between  her  visits.  Sometimes,  when  a  vacancy 
finally  occurs,  the  patient  may  be  contented  with 
home  treatment  and  refuse  to  enter  the  institu- 
tion, or  his  family  may  refuse  to  let  him  go. 
The  nurse  must  do  her  utmost  to  persuade  them. 
She  must  explain  that  in  the  hospital  he  will 
receive  constant,  not  intermittent  care,  and  that 
her  work  will  only  permit  her  to  render  nursing 
service  to  those  who  cannot  otherwise  be  provided 
for.  Should  he  still  refuse,  she  must  continue  her 
visits  of  supervision,  but  must  stop  all  nursing 
care.  No  premium  whatever  should  be  placed 
on  his  remaining  at  home.  This  may  seem  like 
a  harsh  and  unfeeling  policy,  but  it  is  the  only 
course  to  pursue  when  we  take  into  consideration 
the  fact  that  the  institution  is  the  proper  place 
for  an  infectious  disease.  If  a  patient  has  become 
accustomed  to  a  daily  bath  and  other  attentions, 
he  will  miss  them;  when  he  misses  them  badly 
enough,  he  will  consent  to  go  where  they  may  be 
had.  This  plan  does  not  mean  that  the  nurse 
neglects  the  patient, — if  he  suffers,  it  is  through 
choice.  An  excellent  alternative  has  been  offered, 
and  his  refusal  to  accept  it  should  not  entitle  him 


Exceptions  to  Institutional  Care    227 

to  continue  infecting  his  family,  assisted  by  the 
nurse  to  do  it  in  comfort. 

Exceptions  to  Institutional  Care.  A  few  excep- 
tions may  be  made  in  advising  institutional  care. 
For  example,  if  a  family  is  in  good  circumstances, 
with  excellent  home  conditions,  and  the  patient 
is  surrounded  with  every  care  and  attention,  it 
would  hardly  be  necessary  to  counsel  his  removal. 
On  the  contrary,  with  our  present  lack  of  hospital 
facilities,  to  urge  such  a  patient  to  leave  his  home 
might  mean  taking  a  hospital  bed  from  another 
who  needed  it  infinitely  more.  Again,  if  a  tubercu- 
lous child  is  being  cared  for  by  his  mother,  or  some 
one  equally  unlikely  to  contract  the  disease,  it 
might  not  be  worth  while  to  remove  him.  An 
exception  might  also  be  made  in  the  case  of  a 
childless  couple,  advanced  in  years.  The  nurse 
must  use  her  judgment  and  common-sense  in  such 
cases,  where  the  chances  of  infection  are  slight, 
or  non-existent.  On  the  other  hand,  if  there  is 
ample  hospital  accommodation,  and  cases  like 
the  above  ask  for  admission,  they  should  always 
be  taken  in. 

The  cases  in  which  separation  is  imperative 
are  those  in  which  there  is  great  exposure, 
inability  to  control  the  home  surroundings,  ex- 
treme poverty  and  neglect,  or  undue  and 


228          The  Tuberculosis  Nurse 

prolonged  strain  upon  other  members  of  the 
household. 

Compulsory  Segregation.  Not  until  our  hospi- 
tal facilities  are  so  large  that  we  can  accept  every 
case  which  applies  for  admission,  can  we  consider 
forcing  people  to  enter  these  institutions  against 
their  will.  It  is  illogical  to  consider  compulsory 
segregation,  while  we  cannot  accommodate  all 
those  who  voluntarily  ask  for  it.  The  patient 
who  refuses  to  go  to  an  institution  is  probably  no 
more  dangerous  than  he  who  clamours  in  vain  for  a 
bed.  The  docile,  well  intentioned,  kindly  con- 
sumptive is  doubtless  as  much  a  menace  as  the 
selfish,  vicious,  avowedly  careless  one;  in  fact,  the 
former  may  be  more  harmful,  since  his  kindly 
nature  surrounds  him  with  friends,  whereas  the 
latter  forces  people  to  avoid  him. 

As  for  the  tramp,  the  homeless  man  who 
wanders  from  pillar  to  post,  sleeping  in  saloons 
and  lodging-houses,  he  is  far  less  of  a  menace  than 
people  suppose.  He  comes  into  but  casual  rela- 
tionship with  his  fellows,  and  no  one  is  in  pro- 
longed and  intimate  contact  with  him,  as  is 
the  case  of  the  man  in  the  home,  the  centre  of  the 
family  circle.  Until  we  can  accommodate  the 
latter,  we  must  let  the  former  do  as  seems  best  to 
him.  If  ten  anxious  people  are  clamouring  for 


Compulsory  Segregation          229 

every  hospital  bed  at  our  disposal,  why  force  it 
upon  the  reluctant  one  who  refuses?  When  we 
can  handle  the  problem  of  voluntary  segregation, 
it  will  be  time  to  consider  compulsory  measures. 


CHAPTER  XVII 

The  Problem  of  Giving  Relief— The  Giver  of  Relief — Co-opera- 
tion between  Agent  and  Nurse — General  Rules  for  Nurses 
and  Agents — Conditions  of  Asking  for  Relief — Wrong  Con- 
ditions of  Relief  Giving — Incidental  Assistance — With- 
drawal of  Relief — Supplying  Milk  and  Eggs. 

The  Problem  of  Relief  Giving.  Giving  financial 
assistance  or  relief  to  patients  on  or  below  the 
poverty  line  is  a  question  which  sooner  or  later 
confronts  the  nurse  who  undertakes  social  work. 
Long  hours,  overwork,  and  low  wages  produce  a 
class  of  people  who  offer  little  or  no  resistance  to 
disease,  and  when  tuberculosis  once  gets  a  foothold 
amongst  them,  it  is  passed  on  from  one  devitalized 
individual  to  another.  This  is  why  it  is  necessary 
to  remove  a  disease-distributor  from  among  a 
group  of  highly  susceptible  individuals.  For 
example:  let  us  take  a  family  consisting  of  father, 
mother,  and  four  children.  The  father  contracts 
tuberculosis  and  stops  work — his  income  also  stops. 
Even  at  best,  it  was  a  pitifully  inadequate  income, 
and  in  consequence  the  entire  family  is  under- 
nourished, anaemic,  and  generally  run  down.  With 

230 


The  Problem  of  Relief  Giving     231 

the  income  gone,  their  resistance  is  still  further 
lowered,  and  their  chances  of  infection  are  corre- 
spondingly increased.  The  result  is  a  patient 
surrounded  by  a  group  of  people  able  to  offer  but 
slight  opposition  to  this  insidious  disease.  The 
environment,  bad  as  it  was  originally,  grows  worse. 
The  family  moves  into  smaller,  fewer,  cheaper 
rooms,  and  food,  heat,  clothing  are  all  reduced  to 
a  minimum.  This  increasing  poverty  means 
diminished  vitality,  and  heightened  susceptibility 
to  the  threatening  danger.  In  attempting  to 
relieve  this  situation  we  are  dealing  not  with  a 
simple,  but  with  a  twofold  problem — poverty,  plus 
an  infectious  disease. 

Because  of  its  complex  nature,  the  question  of 
giving  assistance  is  a  difficult  and  delicate  matter. 
In  our  efforts  to  relieve  distress  and  want,  we  must 
be  careful  to  do  nothing  which  will  result  in  spread- 
ing tuberculosis.  The  paramount  consideration  is 
the  prevention  of  infection,  and  for  this  reason, 
relief  should  be  made  conditional  upon  the  re- 
moval or  reduction  of  the  danger.  If  we  keep 
this  idea  firmly  before  us,  the  problem  will  be  much 
simplified. 

In  Baltimore,  from  one  third  to  one  half  of  the 
families  under  supervision  are  on  or  below  the 
poverty  line.  This  means  that  they  are  registered 


232          The  Tuberculosis  Nurse 

on  the  books  of  some  charitable  association,  and 
are,  or  at  times  have  been,  dependent  upon  these 
organizations  for  food,  rent,  fuel,  clothing,  or  other 
assistance.  In  other  words,  the  gap  between  the 
income  and  the  cost  of  living  has  needed  to  be 
bridged  over  by  outside  aid.  In  a  new  community 
when  the  nurse's  first  patients  are  the  "poor 
people"  of  the  locality,  she  will  find  that  nearly  a 
hundred  per  cent,  of  her  cases  are  on  the  poverty 
line.  This  was  our  experience  in  Baltimore,  when 
the  work  was  first  organized,  but  now  that  it  is  well 
established  the  percentage  is  much  reduced.  The 
nurses  are  now  working  in  homes  where  economic 
conditions  are  not  acute,  hence  the  number  of 
those  receiving  or  rather  of  those  needing  relief 
(the  terms  are  not  always  synonymous)  is  less 
than  a  few  years  ago.  Still,  distressing  poverty  is 
found  in  from  one  half  to  one  third  of  the  families, 
which  means  that  the  problem  of  fighting  tuber- 
culosis is  gravely  complicated. 

The  Relief -Giver.  When  people  need  financial 
assistance,  the  question  arises,  by  whom  shall  it  be 
given?  a  point  which  provokes  much  discussion. 
Many  people  think  that  the  nurse  should  give  this 
relief,  because  of  her  intimate  knowledge  of  the 
home  conditions  of  the  families  under  her  charge— 
a  knowledge  far  more  extensive  than  that  gained 


The  Relief-Giver  233 

in  any  other  way.  Some  think  if  she  is  socially 
trained,  i.  e.,  supplements  her  hospital  training 
by  a  course  in  a  school  of  philanthropy,  that  she 
can  combine  the  duties  of  both  nurse  and  charity 
organization  agent,  and  become  in  this  way  a  most 
effective  social  worker.  By  this  combination,  the 
family  will  be  spared  the  infliction  of  two  visitors, 
nurse  and  agent,  a  desirable  result,  since  the 
advice  given  by  these  two  workers  is  often  flatly 
contradictory  Other  people  think  that  instead 
of  having  a  nurse,  it  would  be  better  to  have  a 
graduate  from  a  school  of  philanthropy,  with  a 
training  supplemented  by  a  six  months'  hospital 
course.  The  superficial  nature  of  this  course  is 
sufficient  commentary  on  its  value.  Moreover, 
more  than  one  half  of  the  patients  with  tuberculo- 
sis do  not  come  within  the  reach  of  a  relief -giving 
agency. 

These  two  people,  nurse  and  agent,  are  both 
specialists  in  their  own  lines,  and  they  are  equally 
needed.  They  have  had  a  different  training  and 
are  equally  valuable  in  the  field  of  social  service. 
Even  if  it  were  possible,  we  should  not  like  to  see 
these  two  offices  combined  in  one  person — some- 
where there  would  be  a  loss.  It  is  difficult  enough 
to  get  a  first-class  tuberculosis  nurse,  and  it  is 
equally  difficult  to  find  a  first-class  charity  organi- 


234          The  Tuberculosis  Nurse 

zation  agent.  How  much  more  difficult  to  find 
these  combined  in  one  person.  There  is  full 
warrant  for  saying  that  under  no  circumstances 
whatever  should  the  nurse  become  a  relief-giver, 
or  even  remotely  identified  as  such.  In  the  fore- 
going pages  we  have  learned  something  of  the 
extent  and  responsibility  of  her  work,  and  if  she 
concentrates  her  attention  upon  bringing  it  to  the 
highest  degree  of  efficiency,  she  will  find  time  for 
nothing  else.  Moreover,  if  she  becomes  known  as 
one  able  to  give  material  assistance,  her  value  as 
a  public  health  nurse  will  decline.  That  she  can 
give  or  withhold  relief  will  become  known  to  her 
patients,  who  will  follow  or  reject  advice  according 
to  what  they  receive  from  her.  Her  prestige  as 
impartial,  disinterested  adviser  will  at  once  dimin- 
ish, and  the  force  and  authority  of  her  opinion 
be  lost.  Never,  even  by  the  gift  of  a  five-cent  piece, 
should  she  jeopardize  her  unique  position.  The 
well-to-do  patients  will  scorn  her  services,  and 
resent  the  implication  of  her  visits,  while  the  others 
will  follow  advice  when  they  are  bribed,  so  to 
speak,  and  do  as  they  like  when  for  any  reason  this 
bribe  is  withdrawn.  And  other  patients  will  be 
disobedient  or  resentful  if  they  cannot  obtain  what 
their  neighbours  have,  or  what  they  believe  them- 
selves entitled  to. 


Co-operation  Not  Interference    235 

Co-operation  not  Interference.  To  concentrate 
on  one's  specialty  is  all  we  should  ask  of  anyone. 
Any  social  agency  which  scatters  instead  of  con- 
centrates, produces  superficial  work,  which  is  open 
to  well-deserved  criticism.  As  well  expect  a  nurse 
to  become  a  kindergarten  teacher,  because  she 
sees  the  need  for  kindergartens,  or  to  become  a 
playground  teacher  or  settlement  worker,  as  to 
take  upon  herself  the  r61e  of  charity-organization 
agent.  And  the  reverse  of  this  is  true.  We 
should  not  expect  a  relief-giver  to  undertake  a 
nurse's  duties.  It  is  not  the  combination  of  various 
effective  qualities  in  one  person,  but  the  co-opera- 
tion of  various  effective  persons  or  specialists, 
which  counts  in  social  service.  Furthermore,  each 
set  of  workers  should  recognize  its  own  limitations. 
The  line  of  demarcation  should  be  sharply  drawn 
between  the  work  of  one  agency  and  that  of 
another. 

One  sometimes  encounters  an  intense  zeal  which 
causes  one  social  worker  to  try  to  do  her  own,  and 
everyone  else's  work  as  well ;  or  even  worse  than 
this,  to  neglect  her  own  work  in  order  to  do  that 
of  another  person.  All  social  workers  should  learn 
where  to  stop — where  to  transfer  the  case  to  some- 
one else  better  fitted  to  deal  with  another  phase  of 
it.  We  sometimes  hesitate  to  call  in  other  agen- 


236         The  Tuberculosis  Nurse 

cies,  because  they  do  not  recognize  their  boun- 
daries. Co-operation  should  be  substituted  for 
rivalry  and  interference;  when  this  is  brought 
about,  petty  bickerings  and  jealousies  among  the 
social  agencies  will  cease. 

To  become  an  effective  co-operator,  instead  of  a 
critical  interferer,  the  public  health  nurse  must 
familiarize  herself  with  all  the  agencies  in  the  wide 
field  of  social  service.  She  should  try  to  under- 
stand the  object  and  method  of  their  work,  and  to 
know  where  her  own  work  interlocks  with  theirs. 
In  a  way,  they  are  all  interdependent,  one  upon 
the  other,  and  have  the  same  object  in  view — to 
relieve  distress  and  raise  the  sum  total  of  human 
happiness.  Whether  their  work  is  effective  or 
superficial  is  not  our  concern.  The  nurse  should 
understand  what  each  of  them  has  to  offer,  and  by 
picking  here  and  there  among  them,  secure  valu- 
able assistance  for  the  families  under  her  charge. 
She  can  thus  reinforce  her  own  efforts,  and  supple- 
ment her  own  work  in  behalf  of  their  well-being 
and  security. 

Since  nurses  come  in  almost  daily  contact  with 
the  Charity  Organization  Societies  it  should  be 
part  of  their  duties  to  attend  the  local  district 
meetings  of  these  associations,  for  during  the 
discussions  which  take  place,  the  nurses  are  able 


General  Rules  for  Nurses  and  Agents  237 

to  give  most  helpful  information  concerning  their 
own  cases,  while  in  regard  to  other  cases,  not  com- 
plicated by  a  communicable  disease,  they  learn 
much  as  to  the  methods  and  theory  of  relief -giving. 
For  this  reason,  these  district  meetings  are  useful 
to  both  nurse  and  agent  alike;  the  interchange  of 
opinion  enlarges  the  outlook  of  both  workers,  and 
each  gains  an  insight  into  the  difficulties  of  the 
other's  work.  This  interest  and  understand- 
ing promotes  good  feeling,  tolerance,  and  per- 
sonal friendliness — the  basis  of  successful  team 
work. 

General  Rules  for  Nurses  and  Agents.  In  a 
small  community  in  which  there  is  but  one  nurse 
and  no  Charity  Organization  Society  or  its  equiva- 
lent, it  is  well  to  form  a  Relief  Committee,  to  whom 
the  nurse  may  refer  such  of  her  cases  as  need  assist- 
ance. In  cities  where  relief -giving  organizations 
are  already  established,  a  few  general  rules  should 
govern  the  relation  between  nurse  and  agent;  the 
observance  of  these  will  prevent  much  trouble 
and  misunderstanding.  Under  no  circumstances 
should  the  nurse  give  material  assistance — neither 
money,  food,  clothing,  nor  anything  of  the  sort. 
When  these  things  are  needed,  the  agent  should 
be  asked  for  them,  and  no  case  is  so  acute  but 
that  it  may  wait  until  this  consultation  takes 


238          The  Tuberculosis  Nurse 

place.  In  a  city  where  there  is  no  emergency  or 
night  bureau,  it  may  be  necessary  to  make  an 
occasional  exception  to  this  rule,  in  which  case 
the  nurse  may  tide  the  patient  over  till  the  follow- 
ing morning,  when  the  agent  may  be  conferred 
with.  Such  instances  will  be  so  rare,  however, 
that  they  are  merely  noted  as  exceptions  to  the 
general  rule — under  no  consideration  whatever 
should  the  nurse  give  any  material  relief. 

It  sometimes  happens  that  the  nurse  has  been 
given  a  small  sum  to  buy  food,  clothing,  or  special 
articles  for  some  of  her  patients.  This  fund  was 
perhaps  intended  for  a  specified  case,  or  to  be  used 
at  discretion.  It  is  wiser  to  give  this  money  to  the 
agent,  with  the  request  that  it  be  spent  (if  cir- 
cumstances warrant)  as  the  nurse  suggests.  This 
course  may  involve  additional  trouble,  a  little 
extra  work  for  both  nurse  and  agent,  but  it  is 
necessary  to  be  extremely  punctilious  in  order  to 
avoid  serious  misunderstandings. 

When  a  nurse  has  been  in  the  work  a  long  time, 
and  is  dealing  with  agents  whom  she  knows  and 
understands,  a  feeling  of  mutual  trust  and  de- 
pendence will  arise.  Under  such  circumstances, 
both  may  take  far  more  leeway  than  should  be 
granted  a  new  worker — but  unfortunately  this 
happy  and  comfortable  state  is  not  always  reached. 


General  Rules  for  Nurses  and  Agents  239 

The  safest  plan  is  that  each  should  follow  her  own 
line  with  utmost  precision,  being  rigidly  careful 
not  to  overstep  the  boundaries  between  her  own 
and  another's  duties. 

For  example :  a  benevolent  individual  may  give 
the  nurse  an  overcoat,  to  be  used  for  any  patient 
who  needs  it.  The  nurse  knows  a  patient  who  is 
expecting  to  enter  a  sanatorium  in  a  few  days. 
Her  first  inclination  would  be  to  give  him  the  coat 
and  say  nothing.  Apparently  it  concerns  no  one 
but  herself  and  her  patient.  In  adherence  to  the 
rules  laid  down,  however,  she  must  first  consult 
the  agent  before  giving  away  the  coat.  This 
consultation  may  reveal  the  fact  that  the  family 
(new  to  the  nurse)  is  well  known  to  the  Federated 
Charities,  and  that  but  a  short  time  ago  this  patient 
was  given  an  overcoat  which  he  sold  for  drink. 
At  this  time,  be  it  said,  he  was  not  known  to  be 
tuberculous.  Of  course,  this  constitutes  no  argu- 
ment against  giving  him  another  chance,  inasmuch 
as  he  depends  upon  it  to  enter  the  sanatorium,  but 
it  gives  the  nurse  a  side  light  on  her  patient's 
character.  She  should  make  sure  that  he  will  not 
play  fast  and  loose  again;  also  upon  entering  the 
sanatorium  the  physician  must  be  informed  that 
the  man  is  addicted  to  alcohol — a  tendency  to  be 
considered  in  his  treatment. 


240         The  Tuberculosis  Nurse 

•  m 

Tuberculosis,  like  poverty,  is  a  chronic  condition, 
and  the  delay  required  for  wholesome  co-operation 
will  seldom  prove  fatal. 

The  agents,  likewise,  should  be  governed  by  one 
very  simple  rule,  which  will  obviate  all  misunder- 
standings and  ill  feeling.  This  rule  should  be — no 
advice,  suggestions,  or  interference  in  regard  to 
medical  attention,  nursing,  or  treatment.  All  this 
lies  strictly  within  the  nurse's  province  and  should 
be  left  absolutely  to  her.  For  example :  if  an  agent 
enters  a  house  and  finds  a  consumptive,  she  should 
make  no  suggestions  as  to  changing  doctors,  going 
to  this  or  that  dispensary,  or  to  such  and  such  an 
institution.  If  the  case  is  already  known  to  the 
nurse,  the  agent  may  consult  her,  and  find  out 
what  plans  and  arrangements  have  been  made 
and  then  aid  in  bringing  them  about.  If  the  case 
is  unknown  to  the  nurse,  the  agent  should  report 
it  at  once,  leaving  the  nurse  to  take  all  necessary 
steps  as  to  diagnosis  and  treatment.  Grave  results 
often  follow  the  abuse  of  this  one  simple  rule. 
For  example :  an  agent  enters  a  patient's  home,  and 
finds  him  in  charge  of  a  certain  doctor.  Without 
knowing  anything  of  the  circumstances,  she  may 
advise  him  to  change  doctors,  go  to  a  dispensary, 
or  even  to  a  sanatorium.  She  does  not  know  that 
the  patient  is  in  charge  of  a  physician  with  a  large 


Conditions  of  Asking  Relief      241 

private  practice,  and  that  this  is  the  first  time  he 
has  called  upon  the  tuberculosis  nurse.  His  co- 
operation and  help  in  the  tuberculosis  campaign 
depends  upon  the  way  this  first  case  is  handled. 
His  indignation  at  finding  the  nurse  has  played 
him  false  (for  it  is  apt  to  be  the  nurse  who  is 
credited  with  these  objectionable  things)  may  be 
so  great  that  months  of  explanation  cannot  wipe 
it  out.  As  we  have  said  before,  tuberculosis  is 
like  poverty — a  chronic  complaint — and  the  delay 
needed  for  co-operation  will  not  prove  fatal. 

If  nurses  and  agents  will  follow  strictly  this  one 
simple  rule — the  former  to  give  no  material  assist- 
ance, the  latter  to  offer  no  advice  concerning  the 
patient's  treatment — the  chief  cause  of  friction 
between  these  two  sets  of  workers  will  be  elimi- 
nated. 

Conditions  under  which  Relief  is  Asked.  The 
nurse  who  visits  a  family  every  week  or  two  is  in  a 
position  to  know  when  they  have  come  to  the  end 
of  their  resources  and  need  relief.  When  this  point 
is  reached,  she  should  report  the  case  to  the  agent 
of  the  Federated  Charities.  She  must  always 
bear  in  mind  that  her  chief  work  is  the  prevention 
of  tuberculosis;  it  is  not  necessarily  the  prolonga- 
tion of  human  life,  although  the  two  are  sometimes 
coincident.  Relief  should  be  asked  for  if  it  brings 


242          The  Tuberculosis  Nurse 

about  the  prevention  of  tuberculosis,  but  under  no 
circumstances  if  it  means  increased  opportunities 
for  scattering  the  disease.  Under  the  latter  condi- 
tions, assistance  should  be  withheld  or  withdrawn 
as  the  case  may  be. 

For  example:  we  have  a  family  consisting  of 
father,  mother,  and  several  children.  The  income 
ceased  when  the  father,  the  wage-earner,  became 
too  ill  to  work.  The  family  is  in  great  need  of  fuel, 
rent,  and  groceries.  The  giving  of  this  assistance 
should  be  made  conditional  upon  the  removal  of 
the  danger — that  is,  upon  the  patient's  going 
to  an  institution  where  he  will  be  better  cared 
for  than  in  the  home.  By  insisting  upon  this 
removal,  the  Federated  Charities  can  play  an 
important  part  in  the  suppression  of  tuberculosis. 

Suppose  there  are  no  hospital  facilities,  and  it  is 
necessary  to  keep  the  patient  at  home.  In  this  case, 
the  most  susceptible  members  of  the  household, 
namely,  the  children,  should  be  removed.  To 
place  out  children  is  a  difficult  matter,  since  it  is 
hard  to  get  the  parents'  consent ;  this  can  be  done, 
however,  with  time. 

If  this  turns  out  to  be  impossible,  relief  may  be 
given  on  condition  that  the  strictest  precautions 
are  observed.  This  assistance  may  be  given  as 
long  as  both  patient  and  family  follow  rigidly  all 


Wrong  Conditions  of  Relief-Giving  243 

directions  given  by  the  nurse;  failure  to  do  so 
should  be  a  signal  for  the  withdrawal  of  all  aid. 
To  assist  the  patient  who  has  no  choice  but  to 
remain  at  home,  means  to  give  relief  under  the 
least  favourable  conditions,  but  it  must  answer 
when  there  are  no  hospital  facilities.  When  such 
facilities  exist,  no  alternative  should  be  permitted. 
When  a  family  reaches  the  point  where  outside 
interference — social  interference — is  needed,  we 
think  it  not  unreasonable  that  this  assistance 
should  be  given  upon  terms  which  tend  to  pro- 
mote, rather  than  diminish  the  welfare  of  its 
members. 

Wrong  Conditions  of  Relief-Giving.  Relief  is 
sometimes  given  in  a  way  that  makes  it  defeat 
preventive  work,  and  tends  to  create  new  sources 
of  infection.  For  example:  we  recall  a  case  in 
which  the  father  of  a  family  was  in  the  last  stages 
of  consumption.  His  wife  took  in  washing,  and 
was  general  drudge  for  the  patient  and  five  small 
children.  This  man  refused  to  go  to  a  hospital, 
and  also  refused  to  use  his  sputum  cup,  or  take 
any  other  precautions.  Most  of  his  time  was  spent 
in  bed,  and  beside  him  in  the  bed  were  his  two 
small  children,  whose  presence  gave  him  pleasure. 
Neither  doctor,  nurse,  nor  agent  could  bring  about 
a  better  state  of  things,  yet  the  family  was  des- 


244          The  Tuberculosis  Nurse 

perately  poor  and  in  great  need  of  help.  In  con- 
sequence, assistance  was  given  upon  the  patient's 
own  terms  of  being  allowed  to  carry  out  his  right 
to  infect  his  family.  Groceries  were  given  in  large 
amounts,  and  the  patient  himself  was  supplied 
with  abundant  milk  and  eggs,  which  kept  him 
alive  for  weeks  beyond  the  point  where  his  own 
manner  of  living  would  have  ended  the  matter. 
Soon  after  his  death,  one  of  the  children  died  of 
tubercular  meningitis,  while  his  wife  developed  a 
pulmonary  lesion.  All  the  family  are  now  public 
charges. 

We  recall  another  case:  The  family  consisted 
of  the  patient,  his  wife,  and  eight  children.  The 
patient  was  grossly  careless,  declining  to  observe 
the  slightest  precautions,  and  flatly  refused  to 
enter  a  hospital.  After  his  death,  his  wife  and  five 
of  the  eight  children  were  found  to  have  tuberculo- 
sis. During  the  last  six  months  of  his  life,  a  certain 
agency  had  poured  in  unceasing  relief,  thereby 
subsidizing  a  centre  of  infection. 

Still  a  third  case  is  that  of  a  widow,  with  two 
small  children.  She  would  not  part  from  these 
children,  and  refused  to  go  to  a  hospital,  or  to  let 
them  go  to  the  country.  A  separate  bed  was 
provided,  so  that  for  part  of  the  time  at  least  the 
children  might  be  away  from  her,  but  she  declined 


Incidental  Assistance  245 

to  let  them  occupy  it.  She  kept  them  in  bed  with 
her.  Neither  would  she  use  a  sputum  cup  nor 
follow  advice  in  any  way.  All  this  time,  some 
benevolent  old  ladies  kept  her  well  supplied  with 
groceries,  milk,  eggs,  coal,  rent,  and  so  forth,  by 
means  of  which  assistance  she  was  able  to  drag 
out  a  moribund  existence  for  eight  or  ten  months. 
Pitiful  as  this  case  was,  the  utter  selfishness  and 
immorality  of  this  sort  of  "mother  love"  is  some- 
thing which  should  repel  rather  than  attract  the 
sympathies  of  thinking  people. 

These  are  perhaps  extreme  instances,  yet  in  a 
lesser  degree  this  is  what  usually  happens  unless 
relief  is  made  conditional  upon  removal  of  the 
danger.  Charitable  associations  should  be  careful 
not  to  act  as  accessories  in  the  spread  of  tubercu- 
losis, and  should  not  prolong  conditions  under 
which  this  is  practically  inevitable.  If  centres  of 
infection  are  thus  perpetuated,  through  sources 
over  which  the  associations  in  question  have  no 
control,  nurse  and  agent,  at  least,  should  not 
countenance  such  "benevolence." 

Incidental  Assistance.  There  are  many  occa- 
sions when  the  nurse  should  ask  for  relief,  and 
when  this  should  be  freely  and  generously  given. 
When  a  patient  enters  an  institution,  it  may  be 
necessary  to  pension  his  family  during  his  absence ; 


246         The  Tuberculosis  Nurse 

assurance  of  their  welfare  will  enable  him  to  leave 
with  an  easy  mind.  Unless  such  provision  is  made, 
we  are  threatened  with  the  alternative  of  seeing 
him  sit  at  home,  unable  to  work,  but  engaged  in 
the  minor  though  highly  dangerous  occupation  of 
caring  for  the  children  while  his  wife  goes  out  to 
service. 

Relief  may  also  be  of  a  temporary  nature. 
While  a  patient  waits  for  admission  to  a  hospital 
he  may  be  too  sick  to  remain  alone  at  home.  This 
may  mean  that  his  wife,  the  breadwinner,  is  forced 
to  give  up  work  in  order  to  care  for  him.  As- 
sistance should  be  given  during  this  waiting 
period,  after  which  time  the  wife  will  return  to 
her  employment  and  the  family  affairs  readjust 
themselves. 

Again,  we  may  have  a  family  in  which  the 
patient  himself  is  the  only  one  who  needs  help,  the 
income  sufficing  for  all  ordinary  demands,  but  not 
for  the  extraordinary  demands  of  illness.  While 
awaiting  admission  to  an  institution,  it  may  be 
necessary  to  give  him  extra  food,  extra  clothing  or 
bed  clothing,  an  overcoat,  railway  fare,  or  some- 
thing of  like  nature,  either  to  make  him  comfort- 
able, or  to  facilitate  his  removal  when  the  time 
comes.  The  patient  must  not  be  allowed  to  suffer 
during  this  enforced  wait,  but  this  assistance  must 


Incidental  Assistance  247 

not  be  interpreted  as  encouragement  to  remain  at 
home. 

In  the  foregoing  instances,  relief  has  been  con- 
ditional upon  removal.  We  must  sometimes  give 
assistance  under  other  circumstances.  If  there 
are  no  hospital  facilities,  or  if  he  will  not  avail 
himself  of  them,  we  are  doing  good  preventive 
work  if  we  give  the  patient  an  extra  bed,  since  this 
may  result  in  his  partial  separation  from  the 
children  or  other  members  of  the  household. 
Extra  clothing  may  also  be  given  under  like  con- 
ditions. On  the  other  hand,  if  we  gave  milk  and 
eggs  to  the  patient,  we  should  be  supplying  food 
which  would  maintain  indefinitely  a  centre  of 
infection.  (Good  preventive  work  may  be  accom- 
plished by  ample  feeding  of  the  other  members  of 
the  household,  thus  increasing  their  resistance. 
In  this  case  we  should  be  sure  that  this  food  is 
taken  by  the  children,  or  by  those  for  whom  it  was 
intended,  since  otherwise  it  would  be  wasted.) 
Let  us  put  the  matter  very  frankly :  it  is  wrong  to 
prolong  a  patient's  life,  unless  at  the  same  time 
we  can  make  him  harmless  to  those  about  him. 
If  the  two  are  coincident,  well  and  good.  If  not, 
then  the  shorter  the  exposure,  the  better  for  all 
those  who  must  submit  to  it.  We  repeat  what  was 
said  at  the  beginning  of  the  chapter:  the  patient 


248          The  Tuberculosis  Nurse 

on  the  poverty  line  is  surrounded  by  a  group  of 
individuals  whose  vitality  is  at  a  very  low  ebb. 
Our  first  duty  is  to  protect  these  individuals. 

Withdrawal  of  Relief.  When  relief  is  given 
with  the  understanding  that  certain  conditions 
be  complied  with,  it  should  be  withdrawn  if  this 
compact  be  violated.  The  nurse  is  in  a  position 
to  know  of  any  breach  of  faith,  and  should  notify 
the  agent  accordingly.  The  objection  is  some- 
times raised  that  assistance  given  in  this  way  is  a 
bribe,  or  a  threat,  or  a  means  of  coercion,  and  is 
therefore  wrong.  This  rather  overstates  the  case. 
Let  us  say,  rather,  that  under  these  circumstances 
we  have  in  our  Iiands  a  powerful  lever,  by  which 
mountains  of  ignorance  and  prejudice  may  be 
removed.  By  the  use  of  this  lever,  we  can  work 
quickly  and  well  for  the  best  interests  of  the  family 
and  the  community.  We  constantly  see  families 
who  are  not  on  the  poverty  line,  and  over  whom  we 
have  no  control,  yet  who  are  equally  obstinate, 
ignorant,  and  dangerous,  and  regret  infinitely  that 
we  have  no  such  lever  as  in  the  case  of  patients 
who  are  below  the  poverty  line. 

When  asking  for  relief,  the  nurse  must  be  sure 
that  her  patients  will  take  advantage  of  it,  and 
that  she  is  not  sending  the  agent  on  wild-goose 
chases.  Patients  have  sometimes  been  supplied 


Milk  and  Eggs  249 

with  cots,  window-tents,  reclining  chairs,  and 
other  similar  and  expensive  articles,  which  they 
subsequently  declined  to  use.  An  indifferent, 
careless  patient,  unwilling  to  co-operate  in  any 
way,  is  not  one  for  whom  to  demand  such  an 
outlay. 

Milk  and  Eggs.  Ten  years  ago,  milk  and  eggs 
for  consumptives  was  an  integral  part  of  the 
tuberculosis  campaign.  In  those  early  days,  they 
were  considered  as  necessary  as  was  fresh  air  itself. 
They  were  prescribed  as  a  matter  of  routine,  and 
if  the  patient  could  not  afford  to  buy  them,  they 
were  at  once  supplied  by  some  charitable  associa- 
tion. We  have  come  a  long  way  since  then. 

Attention  has  already  been  called  to  the  fact 
that,  in  the  past  few  years,  medical  opinion  has 
undergone  a  great  change  as  to  the  value  of  milk 
and  eggs.  This  rich  and  highly  concentrated  food 
is  considered  far  less  advantageous  than  was  at 
first  supposed.  By  reason  of  their  fat  content 
(especially  the  case  with  eggs),  they  tend  to  cause 
indigestion,  always  a  serious  complication  in  pul- 
monary tuberculosis.  For  this  reason,  the  old 
idea  of  living  on  enormous  quantities  of  milk  and 
eggs  has  been  largely  abandoned.  Some  sana- 
toriums  do  not  give  them  at  all— other  food  is 
substituted,  equally  nourishing  but  less  apt  to 


250         The  Tuberculosis  Nurse 

upset  the  stomach.  Yet  the  idea  that  they  are 
necessary  for  consumptives  dies  hard. 

In  Baltimore,  there  is  now  no  question  of  pro- 
viding them.  During  the  past  year,  nearly  five 
thousand  consumptives  passed  under  the  super- 
vision of  the  Tuberculosis  Division ;  we  asked  that 
milk  and  eggs  be  given  to  only  thirty-eight  of  this 
number.  Of  these  thirty-eight  cases,  thirteen 
were  advanced,  waiting  admission  to  a  hospital; 
two  were  early  cases,  waiting  admission  to  a  sana- 
torium ;  nine  were  suspects,  and  extra  nourishment 
was  needed  in  order  to  facilitate  diagnosis;  and 
fourteen  were  chronic  cases,  to  whom  this  diet  was 
given  as  a  valuable  tonic. 

Quite  apart  from  their  value,  the  real  reason 
that  we  have  ceased  to  give  milk  and  eggs  is 
because  of  our  policy  of  removing  the  patient  to  an 
institution.  The  furnishing  of  this  diet,  or  of  any- 
thing else  which  tends  to  keep  him  at  home,  is 
something  we  do  not  endorse.  We  do  not  wish  to 
place  any  premium  upon  the  home,  or  to  offer  any 
inducements  to  remain  in  it.  If  our  patient  wants 
milk  and  eggs,  we  can  send  him  where  they  may  be 
had. 

If  there  is  no  hospital  for  the  tuberculous  patient 
in  a  community  which  is  able  to  furnish  one,  the 
maintenance  of  the  patient  by  charity  as  a  centre 


Milk  and  Eggs  251 

of  infection,  makes  little  difference,  one  way  or 
the  other.  In  this  case,  the  absence  of  a  hospital 
means  that  the  community  is  merely  sentimentaliz- 
ing and  pottering  over  the  tuberculosis  problem. 


CHAPTER  XVIII 

Home  Occupations  of  Consumptives — Sewing  and  Sweatshop 
Work — Food — Milk  and  Cream — Lunch  Rooms  and  Eating 
Houses — Laundry  Work — Boarding-  and  Lodging- Houses — 
Miscellaneous  Occupations — Summary — The  Consumptive 
Outside  the  Home — Cooks — Personal  Contact  in  the  Factory 
— Supervision  Outside  the  Home. 

Home  Occupations  of  Consumptives.    Up  to 

this  point  we  have  considered  the  patient  solely 
in  relation  to  his  own  family,  or  to  those  with 
whom  he  comes  in  immediate,  constant  contact. 
The  people  surrounding  him  are  in  their  turn 
infected,  transmitting  the  disease  to  others  who 
in  like  manner  are  intimately  exposed.  Roughly 
speaking,  all  of  this  infection  takes  place  within 
the  four  walls  of  the  home.  The  home,  therefore, 
is  the  centre  of  infection, — the  focus  from  which 
tuberculosis  radiates  into  the  community.  The 
further  one  is  removed  from  this  focus,  the  less 
the  danger. 

There  are  certain  ways,  however,  in  which 
danger  from  the  home  threatens  people  who  live 
outside,  people  in  no  wise  connected  with  the 
patient,  and  unaware  of  his  existence.  This 

252 


Home  Occupations  of  Consumptives  253 

occurs  when  the  patient  leaves  his  home  to  seek 
employment  in  the  community,  or  when  he  makes 
or  handles  certain  articles  which  go  forth  into  the 
community  as  carriers  of  bacilli.  Infections  of 
this  sort  may  be  termed  accidental.  They  are 
infrequent  as  compared  to  house  infections,  but 
infrequent  as  they  are,  they  should  be  prevented. 
In  Baltimore,  nearly  fifty  per  cent,  of  the 
patients  under  supervision  are  able  to  work.  They 
seek  a  livelihood  in  office,  factory,  shop,  hotel,  and 
private  home.  We  also  find  that  nineteen  per 
cent,  of  the  families  under  supervision  carry  on 
some  sort  of  gainful  occupation  within  the  confines 
of  their  own  homes.  As  a  rule,  the  patients  who 
conduct  these  little  home  industries  or  occupations 
are  more  advanced  cases  than  those  able  to  find 
employment  in  shops  and  factories.  In  some 
instances,  this  home  industry  was  carried  on  before 
the  patient  became  ill ;  in  others,  by  far  the  greater 
number,  it  is  the  direct  result  of  an  illness  which 
has  modified  his  earning  power  and  compelled 
him  to  eke  out  a  scanty  income  by  this  means. 
In  many  cases  the  actual  work  is  not  done  by  the 
patient  himself  but  by  some  other  member  of  the 
household.  Sometimes  these  industries  are  not 
dangerous  to  other  people,  or  the  risk  is  so  slight 
as  to  be  negligible.  At  other  times,  the  menace 


254          The  Tuberculosis  Nurse 

is  grave.  Each  case  must  be  considered  upon 
its  individual  merits — one  must  not  generalize 
and  condemn  in  wholesale  fashion. 

Sewing  and  Sweatshop  Work.  A  number  of 
our  patients  are  dressmakers,  or  do  factory  sewing 
at  home.  Much  has  been  written  about  the 
danger  of  clothing  made  under  such  conditions, 
either  by  the  patient  himself  or  by  other  members 
of  his  family.  This  output  is  not  as  dangerous 
as  many  people  suppose,  although  such  an  admis- 
sion would  deprive  the  campaign  of  much  pictur- 
esque photography.  Much  of  this  clothing  is  of 
washable  material,  such  as  cotton  shirts,  blouses, 
overalls,  and  the  like,  therefore  any  germs  they 
might  carry  would  be  removed  in  the  first  washing. 
The  danger  has  also  been  exaggerated  in  the  case  of 
woollen  materials,  such  as  coats,  trousers,  etc. 
Any  organisms  contained  in  these  articles  would 
soon  die,  or  their  virulence  become  so  attenuated 
that  little  harm  would  result.  This  also  applies 
to  artificial  flowers.  It  is  not  the  occasional  dose 
of  bacilli,  conveyed  in  this  or  any  other  manner, 
but  the  large  and  repeated  implantations  which 
do  the  damage. 

Infected  clothing  doubtless  plays  considerable 
part  in  the  spread  of  the  acute  contagious  dis- 
eases, such  as  measles,  diphtheria,  and  scarlet 


Food  255 

fever,  but  in  tuberculosis  the  risk  is  so  slight  that 
it  may  almost  be  called  non-existent.  Under  such 
conditions,  the  danger  is  not  to  the  wearers,  or  prob- 
able buyers,  but  to  workers  who  make  this  clothing 
while  in  contact  with  the  consumptive  himself. 

Food.  There  are  other  home  occupations  about 
whose  danger  to  the  public  there  can  be  little 
doubt.  Many  patients  keep  small  grocery  stores, 
confectionery  shops,  and  lunch  rooms,  and  prepare 
and  handle  foodstuffs  of  all  kinds.  Again  we 
must  discriminate.  The  consumptive  who  sells 
tinned  foods  (which  he  does  not  handle),  or  meat 
fish,  or  vegetables  which  are  cooked  before  they  are 
eaten,  is  not  necessarily  spreading  disease  among 
his  customers.  On  the  other  hand,  he  who  sells 
and  handles  milk,  cream,  ice-cream,  bread,  cake, 
candy,  and  so  forth,  is  a  decided  danger  to  all  who 
buy  his  wares.  The  alimentary  tract  is  one  of  the 
main  portals  of  entry  for  the  tubercle  bacilli,  and 
every  precaution  must  be  taken  to  prevent  the 
contamination  of  food.  The  patrons  of  these 
little  shops  are  the  people  of  the  neighbourhood, 
who  are  regular  customers,  and  their  health  is 
endangered  not  by  occasional  but  by  repeated 
doses  of  germ-laden  food. 

Milk  and  Cream.  There  is  an  ordinance  in 
Baltimore  forbidding  the  sale  of  milk  and  cream 


256          The  Tuberculosis  Nurse 

in  a  house  where  there  is  an  infectious  disease; 
this  includes  tuberculosis.  In  order  to  sell  milk, 
it  is  first  necessary  to  obtain  a  permit  from  the 
Health  Department,  but  this  permit  may  be 
revoked  whenever  occasion  demands.  If  the 
nurse  finds  that  one  of  her  patients  is  selling  milk 
(as  is  often  done  in  connection  with  a  small  grocery 
business),  she  reports  this  fact  to  the  Health 
Department.  It  may  be  that  the  patient  himself 
never  comes  near  the  shop,  and  is  out  at  work  or 
away  all  day.  This  sometimes  happens,  but  not 
often.  Usually  he  waits  upon  the  customers 
himself,  selling  milk  in  penny  amounts,  with  a 
dirty  finger  inside  the  measuring  cup.  Or  he 
may  be  too  ill  to  attend  the  shop,  but  sits 
or  lies  in  an  adjoining  room,  so  that  his  wife 
may  wait  upon  him  and  upon  the  customers 
alternately.  Under  such  conditions,  the  danger 
may  be  almost  as  great  as  if  he  himself  han- 
dled the  milk,  since  she  does  not  take  time  for 
proper  cleanliness. 

To  revoke  a  permit  usually  occasions  consider- 
able hardship,  and  the  reduction  of  an  already 
pitiful  income.  Yet  summary  measures  must  be 
taken  unless  the  milk  is  sold  without  risk  to  the 
purchasers  The  patient  should  be  removed  to  a 
hospital,  and  the  family  must  choose  between 


Lunch  Rooms  and  Eating-Houses  257 

letting  him  go  and  giving  up  the  permit.  When 
there  are  no  hospital  facilities  and  the  permit  must 
be  withdrawn,  leaving  the  family  under  financial 
stress,  the  nurse  should  ask  assistance  of  the 
Federated  Charities.  This  assistance,  however, 
should  never  be  offered  as  an  alternative  to  remov- 
ing the  patient  to  a  hospital. 

There  are  other  foods  besides  milk  and  cream 
liable  to  contamination,  the  sale  of  which  is  not 
controlled  in  any  way.  Thus  as  we  have  seen, 
while  a  consumptive  may  be  prohibited  from  sell- 
ing milk,  he  may  sell  ice-cream  without  let  or 
hindrance.  And  furthermore,  an  ice-cream  cone 
or  "snow-ball,"  handled  by  dirty,  germ-laden 
fingers,  is  most  often  sold  to  the  most  susceptible 
of  all  customers — the  child. 

Lunch  Rooms  and  Eating-Houses.  Many  pa- 
tients earn  their  living  by  keeping  eating-houses, 
oyster-parlours,  ice-cream  saloons,  and  so  forth. 
There  is  danger  to  the  customer  whenever  the 
cooking  and  serving  of  food  are  done  by  a  consump- 
tive, or  by  those  in  contact  with  a  consumptive. 
A  community  to  be  well  protected  should  enact 
comprehensive  legislation  controlling  every  aspect 
of  the  food  supply,  and  special  emphasis  should 
be  laid  upon  the  handling  of  food  by  those  with  a 
transmissible  disease. 


258         The  Tuberculosis  Nurse 

Laundry  Work.  Another  home  occupation  is 
laundry  work- — unskilled  labour  requiring  no  capi- 
tal and  largely  resorted  to,  especially  among  ne- 
groes. This  is  heavy  work,  hence  not  always  done 
by  the  patient,  but  often  by  some  other  member  of 
the  household.  Whether  the  patient  irons  the  clean 
clothes  or  sits  coughing  in  the  same  room  where  this 
is  done  (we  have  often  seen  newly  ironed  clothes 
spread  upon  the  bed  of  a  last-stage  case),  the 
result  is  much  the  same.  Under  such  circum- 
stances clothes  become  contaminated.  Since  this 
sort  of  laundry  work  is  usually  done  for  regular 
customers,  they  week  after  week  wear  clothing 
that  has  come  from  an  infected  house.  It  is 
dangerous  to  sleep  constantly  on  pillow  cases  that 
have  been  coughed  on  by  a  consumptive,  and  to 
use  towels  and  napkins  that  have  been  subjected 
to  a  like  infection. 

Since  there  are  no  laws  to  govern  conditions  of 
this  sort,  the  question  arises,  what  is  the  nurse  to 
do  in  such  a  case?  Must  she  look  on  and  say 
nothing,  or  must  she  warn  those  for  whom  this 
laundry  work  is  being  done?  It  would  be  futile 
to  argue  with  the  patient's  family — they  would 
refuse  to  recognize  the  danger  to  others,  seeing 
instead  the  financial  loss  from  giving  up  the  work. 
The  nurse  must  first  try  to  remove  the  patient  to 


Boarding  and  Lodging  Houses    259 

a  hospital,  thus  doing  away  entirely  with  the 
danger.  Failing  in  this  (through  lack  of  hospital 
facilities) ,  the  family  may  be  willing  to  give  up  the 
work  on  condition  that  an  income  be  substituted 
by  some  charitable  agency.  Simple  as  the  latter 
course  may  seem,  so  many  obstacles  to  procuring 
this  aid  will  arise,  that  it  offers  no  practical  solu- 
tion of  the  matter.  If  the  home  surroundings 
cannot  be  altered  and  the  danger  reduced,  then 
the  patrons  or  customers  should  be  told  of  the 
conditions  under  which  their  laundry  work  is  done. 
It  is  not  always  possible,  however,  to  locate  these 
customers,  since  the  patient  is  very  wary  of  giving 
information  upon  this  subject.  Whenever  possi- 
ble, nevertheless,  they  should  be  told ;  if  they  prefer 
to  continue  the  risk,  they  are  at  least  not  in  ignor- 
ance of  it. 

It  is  deeply  regrettable  that  exposure  to  infec- 
tion by  tuberculosis  is  still  an  optional  matter, 
and  that  the  necessary  curtailment  of  individual 
liberty  has  not  yet  been  made  in  regard  to  all 
opportunities  for  it.  In  the  case  of  impure  milk, 
for  instance,  the  law  at  least  makes  an  effort  to 
curb  the  preference  which  any  individual  may 
entertain  for  it. 

Boarding  and  Lodging  Houses.  There  are 
other  home  occupations  in  which  the  menace  is  of 


260         The  Tuberculosis  Nurse 

a  personal  nature,  and  does  not  come  through 
contaminated  articles.  Many  patients  take  in 
boarders — an  occupation  which  frequently  entails 
considerable  overcrowding  of  the  home.  This 
brings  healthy  individuals  directly  within  the 
danger  zone,  and  subjects  them  to  the  same  risks 
incurred  by  the  family  itself.  Other  patients 
take  in  lodgers ;  here  the  risk  is  less,  because  meals 
are  not  included.  In  either  case,  there  is  great 
personal  exposure,  with  equally  great  opportunities 
of  infection. 

Summary.  To  sum  up:  Among  3107  patients 
under  supervision,  we  find  608,  or  19  per  cent., 
carrying  on  some  sort  of  gainful  industry  within 
the  confines  of  their  own  homes.  The  resultant 
danger  is  of  two  kinds :  from  personal  contact  with 
the  patient,  and  the  remoter  possibility  of  infec- 
tion through  articles  which  he  makes  or  handles. 
The  most  serious  risk  is  that  incurred  in  boarding- 
and  lodging-houses,  where  the  inmates  are  sub- 
jected to  a  high  degree  of  personal  exposure.  In 
other  occupations  there  may  be  some  personal 
risk,  but  it  is  slight  and  transitory,  and  therefore 
insignificant.  In  considering  contaminated  arti- 
cles, we  find  there  also  two  classes:  those  danger- 
ous to  a  high  degree,  and  those  but  slightly  so,  if 
indeed  they  may  be  called  dangerous  at  all. 


Summary  261 

Among  the  former,  the  most  harmful  are  the 
contaminated  foodstuffs,  in  which  the  risk  is 
almost  as  great  as  through  personal  contact. 
Next  comes  laundry  work,  where  the  risk  is  in  the 
repetition  of  infection,  as  in  the  use  of  household 
linen.  Then  comes  the  output  of  clothing,  cotton 
and  woollen,  where  also  the  risk  is  slight.  In  the 
case  of  other  articles  handled  by  the  consumptive 
the  risk  involved  is  so  insignificant  as  not  to  be 
worth  mentioning. 

The  following  table  shows  the  nature  of  these 
various  Home  Occupations,  ranged  in  order  of 
their  risk  to  the  community: 

Personal:  Boarders 104 

Lodgers 18  122 

Food:  Bakeries 4 

Confectioneries 4 

Cook  shops 6 

Groceries 73 

Oyster-parlours I 

Saloons 13  101 

Clothing :  Laundry  work 222 

Sewing 109 

Millinery I 

Tailor  shop 4  1 14 

Carried  forward  559 


262          The  Tuberculosis  Nurse 

Brought  forward          559 

Miscellaneous:     Barbers 8 

Basket-maker i 

Cigar  store 2 

Cleaning  and  Dyeing. .      i 

Drygoods 10 

Second-hand  shop.  ...      i 

Shoemaker 21 

Umbrella-mender i 

Wall-paper  shop i 

-46 
Total,  605 

The  Consumptive  Outside  the  Home.  We  must 
now  consider  the  patient  who  is  employed  outside 
the  home.  As  we  have  said  before,  nearly  fifty 
per  cent,  of  our  patients  are  able  to  work.  The 
danger  to  the  public  is  of  two  kinds,  that  arising 
through  personal  contact,  and  through  certain 
articles  which  the  consumptive  may  make  or 
handle.  In  the  latter  case,  just  as  we  find  it 
among  the  home  occupations,  the  risk  to  the  com- 
munity depends  upon  the  articles  themselves. 
Whatever  affects  food,  is  far  more  dangerous  than 
the  contamination  of  articles  not  taken  into  the 
alimentary  tract. 

To  prevent  the  possibility  of  food  infection,  we 
should  enact  and  enforce  laws  forbidding  the 
employment  of  consumptives  in  any  factory,  shop, 
or  establishment  of  any  kind  in  which  food  is 


The  Consumptive  Outside  the  Home  263 

either  prepared  or  sold.  This  would  include  candy 
factories,  bakeries,  cake,  biscuit,  and  cracker  fac- 
tories, canning  and  preserving  establishments,  as 
well  as  dairies,  restaurants,  lunch  rooms,  soda- 
water  stands,  candy  shops,  and  the  like.  We  must 
never  forget  that  the  home  is  the  chief  centre  of 
danger,  the  place  responsible  for  the  vast  majority 
of  infections,  and  that  every  infection  which  occurs 
outside  the  home  is  accidental,  so  to  speak.  Yet 
accidental  infections,  while  relatively  few  in 
number,  are  still  plentiful  enough  to  make  it 
necessary  to  safeguard  the  community  in  every 
way.  An  effective  tuberculosis  campaign  demands 
the  stoppage  of  all  leaks. 

For  example:  on  our  visiting  list  was  a  girl 
employed  in  a  biscuit  factory,  packing  cakes. 
She  was  an  advanced  case,  and  every  now  and  then 
had  a  hemorrhage  which  compelled  her  to  stop 
work,  though  sometimes  only  for  a  few  hours. 
Between  hemorrhages,  she  worked  steadily.  The 
cakes  packed  under  these  conditions  doubtless  car- 
ried a  full  quota  of  germs.  We  tried  to  induce  her  to 
go  to  a  hospital,  but  she  declined.  The  manager 
was  appealed  to  but  he  wanted  to  keep  her — she 
was  a  quick  worker ;  besides,  he  did  not  have  to  eat 
the  cakes — so  he  refused  to  add  his  influence  to 
ours  to  get  the  patient  to  an  institution.  The 


264         The  Tuberculosis  Nurse 

public  should  be  protected  by  law  from  the  pos- 
sibility of  such  infection. 

The  saving  phase  of  the  situation  is  this :  while 
the  patient  who  keeps  a  bakeshop  and  sells  his 
wares  day  after  day  to  practically  the  same  cus- 
tomers, fulfils  the  condition  that  repeated  implan- 
tations are  necessary  to  contract  the  disease;  on 
the  other  hand,  the  cakes  distributed  by  a  factory 
cover  a  wider  range  of  territory — thus,  while  many 
more  people  get  doses  of  germs,  the  doses  them- 
selves are  probably  too  small  to  be  harmful.  This 
also  may  be  said  for  other  kinds  of  foodstuffs, 
handled  in  factories  by  tuberculous  persons ;  these 
articles  are  distributed  so  widely  that  no  individual 
consumer  is  really  endangered.  In  this  way,  the 
risk  is  minimized.  But  still  we  must  remember 
that  every  factory  in  the  country  has  its  tubercu- 
lous employees,  with  their  output  of  bacilli  to  be 
reckoned  with.  The  consumer  is  thus  threatened 
on  every  side.  No  wise  community  should  toler- 
ate such  chances  of  infection. 

Cooks.  There  is  considerably  more  danger 
from  the  tuberculous  cook  employed  in  a  private 
family.  Under  such  conditions  the  household  is 
steadily  infected  day  by  day,  not  through  personal 
contact,  but  by  small,  repeated  doses  of  bacilli 
received  into  the  alimentary  tract. 


Personal  Contact  in  the  Factory   265 

If  typhoid  fever  permitted  a  patient  to  work — 
if  it  were  a  chronic  instead  of  an  acute  disease — 
we  should  consider  it  a  highly  dangerous  expedient 
to  permit  such  a  patient  to  handle  food  in  any 
way,  and  we  should  be  exceedingly  wary  of 
restaurants  which  employed  typhoids  as  cooks  or 
waiters.  This  argument  applies  with  equal  force 
to  tuberculosis.  In  typhoid,  there  is  but  one  portal 
of  entry — the  digestive  tract.  In  tuberculosis 
there  are  two — the  respiratory  as  well  as  the  ali- 
mentary— and  they  are  equally  important. 

Personal  Contact  in  the  Factory.  While  the 
patient  in  the  factory  is  a  menace,  he  is  less 
dangerous  than  the  patient  in  his  home.  A  man 
well  enough  to  work  is  seldom  in  the  most  advanced 
and  infectious  stages  of  tuberculosis.  Moreover, 
his  fellow-workers,  unlike  the  members  of  his 
household,  are  not  in  constant  but  rather  in  casual 
and  intermittent  contact  with  him.  These  two 
conditions  tend  to  diminish  the  risk  to  his  associ- 
ates; still,  it  always  exists.  The  consumptive 
does  not  seek  employment  from  a  malicious 
desire  to  spread  tuberculosis — he  seeks  it  because 
of  economic  conditions  compelling  him  to  work 
until  he  falls  in  harness.  We  must  recognize  this 
driving  necessity,  but  at  the  same  time  we  must 
protect  the  workers  who  perforce  surround  him. 


266          The  Tuberculosis  Nurse 

They  too  are  impelled  by  the  same  need,  and  their 
rights  equal  his. 

When  a  patient  is  visited  at  home,  he  and  his 
family  are  often  stimulated  to  a  high  degree  of 
carefulness.  The  patient  uses  a  sputum  cup  for 
his  own  convenience,  and  the  family  insist  upon 
this  for  their  own  interest  and  safety.  The  result 
is  a  lessening  of  danger,  and  an  improvement  upon 
a  neglected  and  uninstructed  case.  In  the  factory, 
these  conditions  are  reversed.  His  cup  is  no 
longer  a  convenience,  and  he  dreads  being  conspicu- 
ous through  its  use.  Moreover,  since  his  illness  is 
unknown  to  his  fellow-workers,  there  is  no  one  to 
insist  upon  precautions  of  any  kind.  The  result 
is  that  we  maintain  in  the  factory  conditions  which 
we  seek  to  abolish  in  the  home.  We  give  one  set 
of  people  information  whereby  to  protect  them- 
selves, and  we  withhold  this  information  from  an- 
other group  of  people  who  need  it  almost  as  much, 
which  is  illogical  and  stupid  and  costly.  Enormous 
sacrifices  have  been  made  to  this  policy  of  silence, 
and  it  is  time  for  these  sacrifices  to  cease. 

Those  in  contact  with  a  consumptive,  whether 
this  contact  takes  place  in  the  home  or  in  the 
factory,  are  entitled  to  know  the  nature  of  his 
disease.  It  is  not  the  degree  of  consanguinity,  but 
the  degree  of  contact  which  should  determine  this 


Supervision  Outside  the  Home    267 

knowledge.  We  cannot  trust  the  patient  to 
protect  others- — it  is  a  trust  too  often  violated. 
We  must  surround  him  in  the  shop  with  a  public 
opinion  even  more  potent  than  that  which  he  finds 
at  home.  His  fellow-workers  will  be  less  tolerant 
of  breaches  of  technique,  will  make  less  excuse  for 
whims  and  temper,  than  does  the  tired  family. 
We  knew  of  one  patient  who  insisted  on  spitting 
on  the  floor — at  home;  when  his  wife  remon- 
strated, he  knocked  her  down.  In  the  shop, 
such  conduct  would  cost  him  his  place,  and 
rightly. 

Supervision  Outside  the  Home.  Whenever  the 
infectious  case  is  at  large  in  the  community,  his 
whereabouts  should  be  known  to  those  most 
exposed  to  the  danger.  This  applies  alike  to 
employer  and  employee.  The  head  of  the  depart- 
ment in  which  the  consumptive  is  at  work  should 
see  that  those  in  contact  with  him  know  of  his 
condition.  The  patient  should  be  compelled  to 
use  his  sputum  cup  when  he  expectorates.  Know- 
ledge of  the  patient's  condition  does  not  necessarily 
mean  that  he  should  be  dismissed — it  should 
merely  mean  that  he  will  be  held  up  to  the  re- 
quired standard  of  carefulness.  For  example: 
the  Baltimore  Health  Department  received  a 
letter  from  a  certain  firm  in  the  city,  stating  that 


268          The  Tuberculosis  Nurse 

many  cases  of  tuberculosis  had  developed  among 
the  employees  on  a  certain  floor  in  their  factory — • 
and  on  this  one  floor  alone.  This  led  them  to 
suspect  that  a  consumptive  might  be  among 
these  workers,  distributing  the  disease.  A  list  of 
all  the  employees  was  submitted.  Investigation 
promptly  showed  that  on  this  particular  floor  was 
a  chronic  case  of  tuberculosis  of  long  standing, 
a  man  who  had  been  under  supervision  at  home 
for  several  years.  In  his  home,  this  patient  was 
exceedingly  clean  and  punctilious  in  the  use  of  the 
sputum  cup;  at  his  work,  however,  he  was  abso- 
lutely the  reverse.  On  receipt  of  this  information, 
the  employer  had  a  sound  talk  with  this  man, 
which  resulted  in  the  use  of  the  sputum  cup  and 
all  other  precautions.  The  patient  did  not 
lose  his  place,  but  he  was  no  longer  per- 
mitted to  jeopardize  the  health  of  his  fellow- 
workers. 

Patients  with  chronic  tuberculosis  are  also 
found  in  domestic  service,  and  go  in  and  out  of 
private  homes,  carrying  infection  with  them. 
This  danger  is  especially  great  in  the  South,  where 
there  is  a  large  negro  population,  and  we  con- 
stantly find  consumptives  employed  as  cooks, 
housemaids,  nursemaids,  and  butlers,  as  the  case 
may  be.  For  the  most  part,  the  employers  are 


Supervision  Outside  the  Home    269 

entirely  ignorant  as  to  their  condition.  In  these 
cases,  just  as  in  the  factory,  office,  department 
store,  and  so  forth,  the  employer  should  be  notified 
of  the  presence  of  tuberculosis. 

To  give  this  information  should  be  the  duty  of 
the  Health  Department.  The  municipal  nurses 
are  aware  of  the  facts,  and  they  also  know  when  a 
patient  changes  his  occupation,  or  place  of  employ- 
ment. But  to  give  this  information  without 
following  it  up,  would  not  be  enough.  To  notify 
an  employer  of  the  presence  of  a  tuberculous 
worker,  would  not  necessarily  mean  that  any 
action  resulted.  A  poor  workman  might  be 
summarily  dismissed,  and  a  good  one  retained, 
without  those  in  his  vicinity  being  enlightened  as 
to  the  nature  of  his  disease.  To  make  this 
information  of  value,  it  would  be  necessary  to  su- 
pervise the  patient  in  the  factory,  just  as  he  is  su- 
pervised in  the  home.  This  double  supervision 
would  demand  a  greatly  increased  staff  of  nurses, 
since  factory  visiting  should  not  be  done  through 
curtailment  of  the  nurse's  other  duties.  We  must 
once  more  emphasize  the  fact  that  the  home  is  the 
fount ainhead  of  tuberculosis,  and  that  every 
infection  which  occurs  outside  the  home  circle 
(or  its  equivalent)  is  practically  an  accidental 
infection.  But,  as  we  have  already  said,  a  com- 


270          The  Tuberculosis  Nurse 

prehensive  plan  for  checking  tuberculosis  must 
include  the  stoppage  of  all  leaks,  and  the  unknown, 
unsupervised  consumptive,  at  large  in  the  com- 
munity, is  a  leak  which  should  be  recognized  by 
common  sense. 

Yet  certain  conditions  must  be  complied  with 
before  we  can  extend  this  municipal  supervision. 
Outside-the-home  supervision  will  create  an 
enormous  amount  of  phthisiphobia.  Consump- 
tives are  now  tolerated  because  their  presence  is 
either  unknown  or  but  dimly  guessed  at;  when 
this  ignorance  is  dispelled — as  it  must  be  if  the 
nurse  visits  them  at  their  places  of  employment, 
and  their  presence  and  numbers  are  made  known, 
a  great  wave  of  fear  will  spread  over  the  com- 
munity. Such  a  result  is  inevitable  when  for 
the  first  time  the  public  realizes,  suddenly  and 
concretely,  the  extent  to  which  it  is  threatened. 
Tuberculous  workers  will  be  discharged  by  hun- 
dreds, and  there  will  be  widespread  suffering  in 
consequence. 

On  the  other  hand,  however,  thousands  of 
non-tuberculous  workers  will  be  relieved  of  a 
great  danger.  Our  factories  already  produce 
workers  so  worn  out  and  devitalized  as  to  fall 
ready  victims  to  any  disease  that  presents  itself. 
Would  not  these  same  factories  be  somewhat 


Supervision  Outside  the  Home    271 

less  dangerous  if  swept  clear  of  consumptive 
employees?1 

Outside-the-home  supervision  is  the  next  logical 
step  in  the  anti-tuberculosis  campaign.  But 
valuable  as  this  would  be,  from  the  point  of  view 
of  the  general  health,  it  cannot  be  done  until  the 
community  is  prepared  to  care  for  all  who  would 
undoubtedly  suffer  as  a  result.  Some  patients, 
of  course,  would  not  lose  their  situations,  but  the 
majority  would  be  turned  adrift  without  a  mo- 
ment's hesitation.  These  the  community  must 
take  charge  of.  Therefore,  before  we  can  super- 
vise tuberculosis  beyond  the  boundaries  of  the 
home,  we  must  have  ample  hospital  facilities. 
Hospital  accommodation  must  be  so  extensive,  so 
complete,  and  so  excellent  that  institutional  care 
can  be  given  to  all  who  need  it. 

In  this  way,  the  community  will  be  relieved  au- 
tomatically of  a  vast  amount  of  danger.  Patients 
will  either  seek  institutional  care,  or,  if  they  con- 
tinue at  work,  will  do  so  under  conditions  which  do 
not  jeopardize  other  people.  For  the  reaction  from 
the  first  intense  phthisiphobia  will  be  a  demand 

1  However  bad  certain  factory  conditions  may  be,  these  of 
themselves  cannot  produce  tuberculosis  any  more  than  they  can 
produce  scarlet  fever  or  diphtheria.  The  disease  itself  must  be 
brought  into  the  factory  by  a  carrier — someone  who  is  himself 
infected. 


272          The  Tuberculosis  Nurse 

for  carefulness  on  the  part  of  the  consumptive, 
and  sane  toleration  of  him. 

The  one  objection  to  this  policy  of  supervision 
and  publicity  is  the  seeming  interference  with  the 
personal  liberty  of  the  individual,  but  to  curtail 
the  liberty  of  the  patient  to  transmit  a  communic- 
able disease,  is  to  increase  the  liberty  of  hundreds 
to  escape  it.  There  should  be  no  question  as  to 
which  has  the  superior  claim. 


CHAPTER  XIX 

Municipal  Control— The  Danger  of  "Political"  Control— " Poli- 
tics" in  the  Co-operating  Divisions — Results  in  Baltimore — 
Tuberculosis  and  Poverty. 

Municipal  Control.  Tuberculosis  is  a  communi- 
cable disease  in  which  the  patient  himself  must  be 
relied  upon  to  protect  the  community.  We  de- 
pend upon  him  for  whatever  protection  he  chooses 
to  give,  and  whether  this  is  much  or  little  is  deter- 
mined by  his  circumstances,  temperament,  and 
environment.  Whenever  his  ability  or  goodwill 
breaks  down,  we  are  at  his  mercy.  We  may  try  to 
overcome  his  ignorance  by  education ;  to  substitute 
ethical  for  unethical  standards,  and  in  a  more  or 
less  unsatisfactory  way  to  reconstruct  his  im- 
mediate surroundings.  But  the  success  of  these 
efforts  depends,  in  the  last  analysis,  upon  the 
patient  himself.  The  public  is  exposed  to  a  com- 
municable disease,  the  control  of  which  lies  with 
the  transmitter. 

For  this  reason,  a  disease  which  may  be  con- 
tracted by  a  neighbour  becomes  as  much  his  affair 

18  273 


274         The  Tuberculosis  Nurse 

as  it  is  that  of  the  patient  or  possessor.  Should  the 
interests  of  the  two  conflict,  it  is  obvious  that  we 
must  have  some  impartial  arbiter  to  decide  between 
them.  At  such  a  point- — the  right  of  one  person  to 
transmit,  of  another  to  acquire  an  infectious  dis- 
ease— the  matter  becomes  one  of  public  as  well  as 
private  concern.  The  arbiter  between  these  two 
interests  should  be  the  Health  Department  of  a 
community,  and  the  control  of  all  infectious  dis- 
eases should  be  placed  completely  under  the 
municipality. 

In  the  first  chapters  of  this  book,  we  considered 
the  special  nurse  as  supported  by  a  group  of 
private  individuals,  in  connection  with  some 
privately  maintained  association.  Social  experi- 
ments frequently  begin  in  this  way;  when  their 
value  is  proved,  it  should  be  the  aim  of  the  pro- 
moters to  transfer  this  special  work  to  the  depart- 
ment of  the  municipality  in  which  it  belongs. 
Upon  looking  over  the  various  municipal  depart- 
ments, we  realize  that  much  of  what  is  now  freely 
recognized  to  be  municipal  work,  was  originally 
carried  on  through  private  enterprise  and  initia- 
tive. This  is  the  case  with  school  nursing,  play- 
ground work,  juvenile  court  and  probation  work; 
which  in  many  cities  has  passed  through  the  stage 
of  private  enterprise  and  become  firmly  incor- 


Danger  of  " Political"  Control     275 

porated  into  the  city  machinery.  In  all  public 
health  nursing,  the  aim  of  the  founders  should  be, 
first  to  prove  its  worth  to  the  community,  and 
then  make  the  community  (municipality)  assume 
full  charge  of  it  as  soon  as  possible.  It  is  particu- 
larly necessary  to  transfer  tuberculosis  work  from 
private  to  municipal  control. 

The  Danger  of  "  Political "  Control.  The  ques- 
tion of  doing  this,  however,  is  often  a  matter  of 
great  concern  to  the  founders.  They  are  usually 
deeply  interested  in  the  work,  and  have  maintained 
it  upon  a  basis  of  efficiency,  in  spite  of  many 
obstacles.  They  fear,  and  often  rightly,  that  to 
transfer  it  to  the  municipality  will  be  to  transfer  it 
from  the  basis  of  efficiency  in  its  own  line,  to  the 
basis  of  politics,  and  they  dread  that  sinister  con- 
dition known  as  ' '  political  control. ' '  And  yet  the 
administration  of  public  affairs  is  not  necessarily 
"political"  in  the  bad  sense  of  the  term.  On  the 
contrary,  municipal  control  may,  and  in  many 
cities  does  mean,  that  work  is  conducted  with  the 
force,  authority,  and  financial  backing  of  a  great 
department,  such  as  the  Health  Department. 
Under  such  conditions,  it  can  attain  a  far  greater 
degree  of  efficiency  than  could  ever  have  been 
reached  through  private  administration.  Under 
municipal  control,  it  is  possible  to  have  a  large 


276         The  Tuberculosis  Nurse 

staff  of  nurses  and  pay  them  good  salaries — which 
latter  always  means  a  wide  choice  of  applicants. 
It  is  also  possible  to  establish  many  and  well 
equipped  dispensaries,  in  charge  of  salaried,  quali- 
fied physicians.  Money  will  be  forthcoming  for  all 
necessary  expenses  connected  with  the  develop- 
ment and  extension  of  the  work — in  short,  the 
financial  handicap  will  be  removed,  and  the  work 
can  go  forward  with  increased  facilities,  enlarged 
opportunities,  and  heightened  dignity  and  au- 
thority. 

On  the  other  hand,  if  the  administration  of  the 
Health  Department  is  "in  politics,"  the  reverse 
of  this  will  take  place.  Unfortunately,  in  many 
American  cities,  the  business  of  "politics"  is  the 
business  of  providing  people  with  jobs  at  the  tax- 
payers' expense,  regardless  of  the  fitness  of  the 
applicant.  Many  of  our  cities  are  managed  in  this 
way.  Moreover,  in  the  same  city,  this  corruptness 
may  affect  certain  departments  only,  some  being 
negligently  and  dishonestly  conducted,  others 
cleanly  and  efficiently.  Or  we  may  find  both 
conditions  existing  in  a  single  department,  some  of 
whose  branches  or  divisions  may  be  well  conducted 
and  on  a  high  level,  while  other  divisions  may  be 
grossly  mismanaged  and  worthless.  If  a  Health 
Department  is  hampered  by  politics,  either  as  a 


Danger  of  "  Political "  Control    277 

whole  or  in  certain  mismanaged  branches  or 
divisions,  it  is  useless  to  expect  results.  Placed 
under  such  a  handicap,  tuberculosis  work  would 
fail.  Not  only  would  the  taxpayers'  money  be 
wasted,  but  the  community  would  suffer  through  a 
false  sense  of  security,  gained  through  its  faith  in, 
or  rather  its  ignorance  concerning,  a  badly  con- 
ducted department.  To  trifle  with  the  health  of  a 
community  is  a  criminal  act,  and  a  Health  Depart- 
ment which  is  "in  politics"  is  the  most  immoral  of 
all  corrupt  city  departments. 

Evil  results  of  a  Health  Department  being  "in 
politics"  may  be  of  several  sorts.  For  example: 
the  Superintendent  of  Nurses  may  be  an  inexperi- 
enced, incapable  woman,  appointed  by  a  ward 
politician  to  clear  off  political  debts.  A  ward 
politician  is  hardly  one  whose  judgment— 
in  nursing  matters  at  least — should  be  relied 
upon. 

On  the  other  hand,  the  Superintendent  herself 
may  be  capable  and  efficient,  but  she  may  not  be 
permitted  to  select  the  members  of  her  staff.  In- 
stead of  being  able  to  choose  them  herself,  accord- 
ing to  their  fitness  and  ability,  she  must  accept  any 
unqualified  woman  whom  the  ward  boss  may 
appoint.  A  staff  of  incompetent  nurses,  appointed 
without  regard  to  character  or  education,  is  not  a 


278         The  Tuberculosis  Nurse 

force  from  which  to  expect  results.  Moreover, 
nurses  chosen  in  this  manner  feel  that  they  are 
' 'protected"  and  can  do  as  they  like,  subject  to 
neither  restraint  nor  discipline.  This  means  that 
their  work  cannot  be  controlled,  corrected,  or 
directed  in  any  way.  Dismissal  can  be  made  only 
for  the  most  flagrant  offences — not  for  any  such 
trifle  as  incompetence,  laziness,  or  stupidity. 
When  the  Superintendent's  hands  are  thus  tied — • 
when  she  cannot  select  her  nurses,  cannot  control 
them,  and  cannot  dismiss  the  worthless  as  well  as 
the  unscrupulous,  the  result  is  a  low  grade  of  work. 
No  able  and  self-respecting  woman  could  hold  the 
position  of  superintendent  under  such  circum- 
stances, thereby  making  herself  responsible  for 
work  which  she  cannot  control. 

The  acceptance  of  registered  nurses  only,  and  the 
requirement  of  Civil  Service  Examination  in  addi- 
tion, would  do  much  to  raise  the  level  of  efficiency. 
These  requirements,  however,  valuable  as  they 
are,  would  by  no  means  ensure  the  suitability  of 
the  applicant,  or  guarantee  the  selection  of  nurses 
best  adapted  to  public  health  work.  Over  and 
above  this,  the  Superintendent  should  have  free 
choice  in  selecting  her  workers,  not  only  from  the 
point  of  view  of  education,  but  also  that  of  personal 
worth. 


" Politics"  in  Co-operating  Divisions  279 

"  Politics "    in    the    Co-operating    Divisions. 

Sometimes  the  Tuberculosis  Division  itself  may 
not  be  on  a  political  basis,  but  the  various  other 
divisions  of  the  Health  Department  may  be  con- 
ducted in  such  a  manner  as  to  nullify  much  of  the 
nurses'  work.  For  example:  much  depends  upon 
the  co-operation  of  the  Fumigation  Division.  If 
the  men  employed  to  fumigate  houses  do  their 
work  badly  or  improperly — If  they  are  too  lazy 
to  stop  chinks  and  crevices,  thus  permitting  the 
disinfectant  to  leak  out ;  if  too  ignorant  to  properly 
measure  the  rooms,  and  unable  to  calculate  the 
necessary  amount  of  formaldehyde,  this  work  will 
be  valueless.  Worse  still  if  they  are  the  kind 
that  can  be  "bought  off"  and  so  shirk  work 
entirely. 

Or  the  trouble  may  be  with  the  Sterilization 
Division,  where  the  duty  of  the  employees  is  to 
carry  mattresses,  etc.,  from  the  patient's  home  to 
the  city  sterilizer.  When  there  is  no  law  com- 
pelling this  sterilization,  and  it  is  an  optional 
matter  with  the  householder,  if  done,  its  doing  is 
altogether  the  result  of  the  nurse's  teaching  and 
advice.  If  the  waggon  drivers  are  lazy  and  do 
not  wish  to  carry  the  heavy  mattresses,  they  can 
shirk  work  by  means  of  false  excuses  often  difficult 
to  detect.  For  example :  they  can  report  that  when 


280          The  Tuberculosis  Nurse 

a  certain  mattress  was  called  for,  the  family  had 
changed  their  minds  about  having  it  sterilized  and 
refused  to  have  it  done.  Upon  investigation,  we 
find  that  this  refusal  was  at  the  instigation  of  the 
waggon  driver  himself — he  had  assured  the  family 
that  sterilization  was  an  unnecessary  and  stupid 
proceeding.  To  ignorant  minds,  one  Health 
Department  employee  is  as  good  as  another,  and 
when  the  advice  is  conflicting,  they  choose  that 
which  best  pleases  them. 

Again,  the  fumigators  or  drivers  may  report  that 
they  cannot  get  into  a  certain  house ;  the  key  could 
not  be  found;  there  was  no  one  to  admit  them, 
or  give  them  the  articles  to  be  removed.  In  in- 
numerable ways  they  may  compel  the  nurse  to 
return  again  and  again  to  the  same  house,  to  make 
arrangements  which  they  try  to  frustrate  by  every 
conceivable  device. 

If,  therefore,  the  employees  of  the  various  co- 
operating divisions  are  mere  jobholders — if  they 
are  neither  honest  nor  intelligent,  nor  interested 
in  anything  but  pay-day — it  is  a  heartbreaking 
task  for  the  honest  and  efficient  division  to  work 
with  them.  All  of  these  activities  interlock,  and 
must  work  together  to  gain  a  common  goal.  If 
all  are  operated  at  their  highest  level,  working 
in  close  and  intelligent  accord,  then  indeed  we 


Results  in  Baltimore  281 

may  expect  results.  But  if  the  reverse  is  the  case — • 
if  the  co-operating  divisions  are  a  drag  and  a 
hindrance — then  the  task  is  overwhelming.  The 
weak  are  corrupted  and  the  strong  discouraged. 

Those  responsible  for  placing  tuberculosis  work 
under  the  city's  administration — where  it  right- 
fully and  logically  belongs — should  continue  their 
interest  still  further.  It  is  not  enough  to  transfer 
it  from  pioneer,  private  control,  and  then  drop  the 
responsibility. 

If  a  Health  Department  is  clear  of  politics,  and 
all  its  divisions  work  together  harmoniously,  mag- 
nificent results  may  be  obtained.  Power,  prestige, 
and  efficiency  is  a  combination  which  results  in 
forceful  work. 

Results  in  Baltimore.  Results  have  been 
achieved  in  Baltimore  by  reason  of  a  well-managed 
Health  Department,  acting  in  close  co-operation 
with  the  institutions  of  both  city  and  state.  The 
tuberculosis  machinery  consists  of  a  staff  of 
seventeen  special  nurses ;  three  special  dispensaries 
with  a  physician  in  charge ;  a  laboratory  for  sputum 
examinations;  a  fumigation  corps  and  a  steam 
sterilizer.  With  this  force,  we  work  in  connection 
with  three  other  tuberculosis  dispensaries,  and  six 
institutions  for  the  care  of  early  and  advanced 
cases.  Some  of  these  institutions  are  maintained 


282          The  Tuberculosis  Nurse 

by  state  appropriations,  others  by  both  public  and 
private  funds.  The  co-operation  between  these 
institutions  and  the  Health  Department  is  abso- 
lute ;  if  the  control  was  all  through  one,  instead  of  a 
dozen  different  centres,  it  could  not  be  more 
complete  or  harmonious.  Failure  in  any  one  direc- 
tion is  felt  down  the  line,  consequently  each  is 
stimulated  to  its  best  effort.  Thus,  the  nurse 
knows  that  if  she  fails  to  persuade  her  patient  to 
enter  the  hospital,  the  hospital  is  useless,  or  that  if 
the  bad  food  of  the  hospital  drives  the  patient 
back  again  to  his  home,  the  nurse's  work  goes  for 
nothing.  Each  reacts  upon  the  other,  and  as  all  are 
working  for  the  same  end,  there  is  constant  incen- 
tive to  become  a  strong,  rather  than  a  weak  link 
in  the  chain.  The  results  obtained  cannot  be 
measured  in  terms  of  individuals — we  cannot 
point  to  so  many  patients  improved,  so  many 
working,  and  so  forth.  Individual  welfare  is  too 
shifting  and  too  questionable  a  standard  by  which 
to  judge.  The  only  absolute  standard  is  that 
afforded  by  the  death-rate.  A  declining  death- 
rate  means  also  a  decreasing  morbidity — fewer 
people  die  of  tuberculosis  and  fewer  are  infected. 
While  our  tuberculosis  death-rate  is  still  enor- 
mously high,  it  is  nevertheless  falling  year  by 
year.  Thus  we  see; 


Tuberculosis  and  Poverty        283 

Deaths  from  Pulmonary  Tuberculosis : 

1909 1400 

1910 1234 

1911 1165 

1912 1189 

1913 1129 

There  is  nothing  spectacular  about  this.  It  is 
heartbreakingly  slow — needlessly,  uselessly  slow 
work.  Yet  it  is  progressing  in  the  right  direction. 
Tuberculosis  and  Poverty.  Throughout  the 
foregoing  pages  we  have  considered  the  direct 
method  of  dealing  with  tuberculosis — the  removal 
or  segregation  of  the  distributor.  But  there  is 
also  an  indirect  method  of  dealing  with  tuber- 
culosis, namely  the  abolishment  of  poverty. 
Tuberculosis  recruits  full  fifty  per  cent,  of  its 
ranks  from  people  of  a  certain  social  level — the 
very  poor.  This  class  is  composed  of  people 
habitually  overworked,  underpaid,  and  subject 
to  all  the  deteriorating  influences  of  unsanitary 
and  vicious  environment,  and  to  the  ignorance  and 
degradation  which  follow  in  the  wake  of  extreme 
distress.  The  root  cause  of  these  conditions  is  our 
present  unjust  economic  system,  which  produces 
an  excess  of  luxury  and  frivolity  on  the  one  hand, 
and  on  the  other  an  army  of  people  who  must 
forego  the  barest  necessities  of  life.  One  class  is 


284         The  Tuberculosis  Nurse 

maintained  at  the  expense  of  the  other.  Every 
movement  which  seeks  to  abolish  this  injustice, 
and  to  substitute  a  fairer  and  more  equable  system, 
is  a  movement  which  at  the  same  time  tends  to 
raise  the  standard  of  public  health.  Any  .legisla- 
tion, social  or  revolutionary,  which  makes  for  the 
improvement  of  industrial  conditions,  raises  the 
level  of  public  health  through  raising  the  welfare 
(i.e.,  resistance)  of  the  individual.  Therefore, 
sweeping  readjustment  of  social  and  economic 
conditions  would  automatically  eliminate  an  enor- 
mous amount  of  disease,  by  reducing  the  number  of 
highly  susceptible  individuals.  To  increase  the 
number  of  people  with  high  resistance — or  to 
decrease  the  number  of  people  with  low  resistance, 
whichever  way  one  chooses  to  put  it — would 
probably  diminish  the  amount  of  tuberculosis  by 
about  one  half. 

This  indirect  method — the  readjustment  of 
social  conditions  and  the  abolishment  of  poverty — 
valuable  as  it  would  be,  would  still  leave  the  prob- 
lem unsolved.  Even  diminished  by  one  half,  the 
amount  of  tuberculosis  would  still  be  formidable, 
and  we  should  have  to  attack  it  as  vigorously  as 
ever,  if  not  to  the  same  extent.  The  disease  would 
still  exist,  just  as  it  now  exists  in  well-to-do  families 
in  small  towns,  in  rural  districts,  and  in  other  cir- 


Tuberculosis  and  Poverty         285 

cumstances  attributable  to  neither  poverty  nor  bad 
industrial  conditions. 

A  thousand  years  ago,  industrial  conditions 
were  as  distressing  as  those  which  exist  to-day — 
yet  in  those  days  the  poor  staggered  under  the 
additional  burden  of  leprosy.  A  hundred  and 
fifty  years  ago  poverty  was  complicated  by  small- 
pox, the  scourge  of  Europe.  The  rigid  segregation 
of  lepers  in  the  Middle  Ages  relieved  the  situation 
of  leprosy,  while  the  discovery  of  vaccine  has 
practically  eliminated  smallpox.  The  submerged 
classes,  while  their  economic  condition  remained 
unchanged,  were  at  least  relieved  of  the  added 
weight  of  these  two  great  diseases.  So  in  our 
present  fight  against  tuberculosis.  An  aggressive 
campaign  against  this  disease  will  not  necessarily 
improve  industrial  conditions,  but  those  who  suffer 
most  from  these  conditions  will  be  relieved  of  one 
more  handicap. 

In  our  present  warfare  against  tuberculosis  we 
are  not  impelled  by  the  blind  fear  that  made 
society  in  the  Middle  Ages  demand  segregation, 
and  refuse  to  tolerate  an  infectious  disease  at 
large  in  the  community.  Nor  has  any  vaccine  or 
similar  agent  been  discovered  by  which  the  disease 
may  be  wiped  out.  Instead,  we  must  depend  upon 
a  campaign  of  education — wholesale,  widespread 


286          The  Tuberculosis  Nurse 

education,  conducted  amongst  all  classes  of  society. 
We  know  the  path  to  be  travelled,  and  the  machin- 
ery by  which  we  may  gain  our  ends.  If  at  any 
time  we  become  impatient  with  our  slow  rate  of 
progress,  we  can  accelerate  our  speed  by  the 
extension  and  multiplication  of  the  three  funda- 
mental agencies  in  the  anti-tuberculosis  campaign 
—the  Hospital,  the  Dispensary,  and  the  Public 
Health  Nurse. 


INDEX 


ADVANCED  cases,  46-47,  119, 
145,  223,  224-227;  see  Pa- 
tients and  Segregation 

Air,  fresh,  145-147 

Alcohol,  151 

Ambulatory  cases,  33,  34,  38, 
79-80;  see  Patients 

Anti-tuberculosis  campaign,  I- 
3;  fundamental  agencies  in, 
286 

Anti-tuberculosis  Society,  5-6 

Arrested  cases,  2;  nursing  as 
work  for,  13-14;  see  Patients 


B 


BACILLI,  tubercle,  articles  in- 
fected by,  253;  distribution 
of,  169,  262-266;  presence 
or  absence  in  sputum,  107- 
108,  in;  tenacity  of,  170 

Badges,  31 

Bag,  nurse's,  41;  supplies  car- 
ried in,  42-46,  108 

Baltimore,  branch  offices  for 
tuberculosis  nurses,  39;  co- 
operation of  nurses  with 
institutions,  202,  204-205, 
281-282;  dispensaries,  92, 
151,  186-187,  192,  198-199, 
201-202;  examination  of 
nurses,  12;  forms  used  for 
charts,  etc.,  50-59;  Health 
Department,  42,  157,  170- 
171,  174,  176,  183-192,  204, 
206,  250,  256,  267-268,  279- 
282;  milk  and  eggs  for  pa- 


tients, 250;  nurse's  bag,  41; 
nurses'  districts,  39  note; 
occupations  of  patients,  253, 
261-263;  ordinance  in  regard 
to  selling  milk,  255-256; 
organization  of  tuberculosis 
work,  200-202 ;  poverty,  231- 
232;  registration  of  cases, 
112;  salary  of  tuberculosis 
nurse,  21;  sick  leave,  28; 
supplies  for  patient,  42; 
Tuberculosis  Division,  171, 
183,  201-202,  250;  uniforms, 
30-31;  vacations,  28;  Visit- 
ing Nurse  Association,  8, 
39,  42,  65,  201,  202 
1,  for  advanced  cases,  145; 
placing  of,  144 

Bedclothing,  144 

Bedding,  disinfection  of,   175, 
176 

Bedroom,  patient's,   137-140 

Board  of  examiners  for  nurses, 
II 

Board  of  Health  of  Maryland, 
42;  furnishes  formaldehyde, 

173 

Books  of  instruction,  44 


CABOT,  DOCTOR,  quoted,  70 
Calls,  night,   16;  sources  from 

which  received,  121 
Calmette  test,  1 1 1 
Card  index,  53-54 
"Careful    consumptive,"    the, 

220-223 
Carpets,  infected,  178-179 


287 


288 


Index 


Cases,  tuberculosis,  see  Ad- 
vanced, Ambulatory,  Arrested, 
and  Discharged  cases;  and 
Patients 

Cases,  undiagnosed,  63, 99-101 
Charity  Organization  Society 
(or  Federated  Charities), 
39,  66,  98,  108,  109,  176, 
210,  236-237,  239,  241,  242, 
245;  rules  for  agents  of,  237- 
241 

Charts,  patients',  49-54,  58-60 
Children,  care  of  tuberculous, 
163;  diagnosing,  161-162;  in- 
fection of,  95,  in,  151-152, 
159-164;  open-air  schools  for, 
163-165;  sending  to  school, 
162-163;  pre-tuberculous, 
163 

Classes,  tuberculin,  196-197 
Cleaning   should    be    compul- 
sory, 182-183;  see  Disinfec- 
tion 

Clothing  for  tuberculous    pa- 
tients, 142-143,  2 i 1-2 12 
Cooking,   supervision   of,   and 
instruction  in,  by  nurse,  149- 

151 

Cooks,  infection  from,  see 
under  Infection 

Co-operation,  between  institu- 
tions and  nurse,  203,  205- 
208;  of  newspapers  in  tuber- 
culosis work,  5;  of  organiza- 
tions for  social  work  and 
nurse,  35~36,  143,  156-15?, 
176-177,  182,  210;  wrong 
methods  of,  33-34;  see  also 
Charity  Organization  Society 
and  Social  Workers 

Country,  the,  for  tuberculous 
patients,  165-168 

Cullen,  Doctor  Victor  P., 
quoted,  108 

Cure  of  tuberculosis,  4,  125- 
127,  208-209 

D 

DAILY  reports,  55-57 
Day  sheet,  57 


Death  of  patient,  49,  119,  120; 
reporting,  53,  171 

Diagnoses,  erroneous,  92-97, 
101;  lack  of,  63;  "lay,"  68- 
69,  100 ;  necessity  for  formal, 
1 15-116;  obtaining,  105-107, 
184-185;  from  sputum,  107- 
109;  value  of  recording,  114- 
115;  volunteered  by  physi- 
cians, 106 

Diet  of  patients,  147-150,  249- 

251 

Discharged  cases,  204-205, 207, 
209;  see  also  Arrested  cases 

Disinfectants,  43-44,  133,  173 
note 

Disinfection,  by  boiling,  131- 
132,  177,  178;  by  burning, 
175,  178,  179,  183;  by  clean- 
ing, 138,  172;  by  fumigation, 
170-173,  176,  179,  180,  181, 
182,  183;  by  painting  and 
papering,  179;  by  steam 
sterilization,  175-177;  effects 
of,  on  materials,  176  note 

Dispensaries,  general,  107;  tu- 
berculosis, consideration  for 
patients  at,  189-190;  equip- 
ment of,  186-188;  establish- 
mentof,io5,  185;  hours,  188- 
189,  196;  importance  of,  286; 
necessity  for,  105,  184-185; 
nurses'  work  in,  194-195, 
197-199;  obtaining  patients 
from,  67-68;  physicians' 
work  in,  191-194;  reports 
made  to,  by  nurse,  202;  tak- 
ing patients  to,  159;  see  also 
Baltimore,  Diagnosis,  Nurse 

Districts,  35-36,  39  note 

Duplication  of  work,  33-34 


EDUCATION  unsuccessful  as  pre- 
ventive measure,  2-3 

Examination  of  patients, 
nurses,  etc.,  see  Diagnosis, 
Dispensary,  Families,  Health 
Department,  Nurse,  Patients, 
Physician,  Sputum 


Index 


289 


Expenses  of  nurse,  24-26 
Eye  test,  in 


FACTORIES,  spreading  of  tuber- 
culosis in,  266-267,  271  note; 
supervision  of  patients  in, 
267;  see  also  Patients,  oc- 
cupations of 

Families  of  patients,  co-opera- 
tion with  nurse,  127,  174; 
examination  of,  157-158; 
hygiene  of,  155;  infection  of , 
68-69,  97;  relations  with 
nurse,  152;  recreations  of, 
155-156;  respect  for  customs 
of,  181-182;  see  also  under 
Children  and  Nurse 

Food,  importance  to  patient 
of  proper,  147-150;  see  also 
under  Diet,  Infection,  Nurse, 
instruction  by 

Formaldehyde,  formula  for, 
173-174  note 

Forms,  see  Charts,  Records, 
Reports 

Fumigation,  see  under  Balti- 
more, Disinfection 


H 


HAMMAN,  DOCTOR  Louis, 
quoted,  in 

Health  Department,  badges, 
31-32;  co-operation  with  in- 
stitutions, 205-207;  dispen- 
saries, 185;  examination  of 
sputum  by,  187;  laws  in 
regard  to  tuberculosis,  76- 
77,  112;  notifying  employers 
of  tuberculosis  patients,  269; 
physicians  of,  89;  politics  in, 
275-278 ;  registration  of  cases 
with,  112,  of  deaths,  171; 
reports  from  institutions  to, 
206;  supervision  of  dis- 
charged patients  through, 
207;  supplies  provided  by, 
42;  visiting  physicians 


needed  by,  184-185;  see  also 
under  Baltimore,  Disinfection 

Heat,  artificial,  in  outdoor 
treatment,  143,  147 

Histories,  see  under  Patients 

Home,  "breaking  up  the," 
161;  care  of  advanced  pa- 
tients at,  225-227;  condi- 
tions in  patients',  139,  148, 
160,  163;  entering  patients', 
31,  1 1 8,  122;  see  Infection 

Hospitals,  for  advanced  cases, 
207-208,  218-219;  impor- 
tance of,  in  tuberculosis,  223, 
271,  286;  opposition  to  build- 
ing of  tuberculosis  hospitals, 
2 1 9-22 1 ;  sending  patients 
to,  207-208;  special  wards 
for  tuberculosis,  218-219 

Houses,  inspection  of,  by  nurse, 
136-137;  vacant,  watched 
by  nurse,  181 


INFECTION,  of  children,  159- 
160;  sources  of,  140,  159- 
160,  165-168,  252,  255-268; 
see  also  under  Advanced 
cases,  Ambulatory  cases,  Ba- 
cilli, Children,  Factories , 
Families,  Patients 

Institutions,  see  Hospitals  and 
Sanatoria 

Instruction,  books  of,  44;  of 
patients  and  families,  127- 
133,  142-148;  see  also  under 
Nurse 


LANDLORD,  irresponsibility  of, 
180-181 

Laws,  for  proper  disinfection, 
183;  for  protection  from  in- 
fection, 264;  for  registration 
and  reporting  of  tuberculosis 
cases,  7,  111-112;  State,  in 
regard  to  tuberculosis,  76, 
77 


290 


Index 


"Light  work"  for  tuberculosis 

patients,  215-216 
Lyman,     Doctor    David     R., 

quoted,  213 

M 

MARYLAND,  State  Board  of 
Health,  quoted,  213;  neglect 
of  law  for  registration  of 
tuberculosis  cases,  113;  Tu- 
berculosis Association,  8 
note 

Milk,  infection  through,  255 
Milk  and  eggs,  see  Diet 
Minor,     Doctor    Charles    L., 

quoted,  126 

Municipal  control  of  tuber- 
culosis work,  77-86,  89-91, 
274-275;  see  also  Baltimore 


N 


NAPKINS,  paper,  use  of,  130- 

131 

Newspapers  as  agents  in  tuber- 
culosis work,  5 

Nurse,  the  tuberculosis,  "as- 
set to  community,"  199; 
access  to  cases,  121-122; 
calls,  121-122;  character, 
16-19;  co-operation  with 
physician,  88,  103,  109; 
discovering  cases,  67;  dis- 
pensary work,  194-199;  dis- 
trict, 35-36;  duties  of,  46, 
48-49,  52,  53-56,  58-59,  62- 
70,  100-101,  105,  106,  108- 

109,    122,    128-137,    149-153, 

154-157,  169-170,  181-183, 

204-205,  2O7-208,  2 1 1-2 12, 
213,  216-217,  224,  258-259; 

establishment  of,  7-10,  89; 
expenses,  24-26;  function, 
117-118,  224,  247-248;  giv- 
ing relief,  232-233,  237,  241- 
242,  245-248,  health,  12-15; 
hours  on  duty,  14,  36;  in- 
struction of  patients  and 
families,  127-131,  133-148, 


155-156,  172,  174,  178,  183' 
lunches,  40-41;  noon  hour, 
40-41;  office,  38-40;  physi- 
cal examinations,  12-13;  re- 
lations with  patients'  and 
families,  18,  123,  133,  152- 
153,  181-182;  relations  with 
physicians,  71-73,  87-89,  92- 
94,  99-104,  123;  responsi- 
bility to  community,  to 
patient  and  family,  118; 
to  organization,  89;  salary, 
20-23;  sick  leave,  27-28; 
social  worker  as  nurse,  233- 
234;  time  off,  14-16;  training 
of,  10-12,  62;  uniforms,  28- 
31;  vacation,  26-27;  visits, 
36-38;  visiting  list,  63-70; 
see  also  under  Baltimore, 
Charts,  Children,  Co-opera- 
tion, Diagnosis,  Diet,  Dis- 
infection, Dispensaries,  Fam- 
ilies, Health  Department, 
Home,  Registration,  Reports, 
Visiting  Nurse  Association 


OCCUPATIONS  of  patients,  see 
under  Infection 

Office  of  tuberculosis  nurse, 
38-40 

Open-air,  schools,  163;  treat- 
ment, 140-143 

Organizations,  see  under  Char- 
ity Organization  Society,  and 
Co-operation 

Outdoor  work  for  tuberculosis 
patients,  216 


PATIENTS,  bedridden,  151-152; 
carelessness  of,  97,  214-222, 
266- 268;  changing  physi- 
cians, 80-8 1,  92-96,  98-100; 
charts,  48-53;  co-operation 
with  nurse,  248-249;  dis- 
charged, 204-207,  212- 
215;  employment  of,  262; 


Index 


291 


PATIENTS — Continued 

examination  of,  158,  190; 
histories,  123-124;  home 
occupations,  261-262;  iso- 
lation of,  in  homes,  151- 
152;  limitation  of,  33,  200; 
objection  of,  to  institutions, 
210-211;  outdoor  treatment, 
144;  rest  for,  143-144;  send- 
ing to  country,  165-168;  su- 
pervision outside  the  home, 
267-272;  supplies  for,  42-43, 
45;  telling  the  truth  to,  124- 
127;  see  also  Advanced,  Am- 
bulatory, and  Arrested  cases, 
Baltimore,  Children,  Diet, 
Dispensaries,  Families, 
Health  Department,  II  o  m  e, 
Infection,  Instruction,  Nurse, 
Segregation,  Relief 

Phipps  Dispensary,  see  Dis- 
pensaries under  Baltimore 

Phthisiphobia,  14,  134-135, 
270-272 

Physicians,  incompetent,  93- 
97,  101-104;  municipal,  90; 
standards  of,  83;  report- 
ing tuberculosis  cases,  113; 
State  requirements  of,  75-76; 
"  unethical  practitioner," 
the,  72,  84,  85;  see  also  under 
Diagnosis,  Dispensaries, 
Nurse,  Patients 

Pockets,  waterproof,  44 

Poverty,  relation  to  tubercu- 
losis, 3-4,  61,  80-8 1,  230- 
232,  265,  283-285 

Prevention  of  tuberculosis,  4, 
120,  155-156,  159-161,  247- 
248;  see  also  under  Disinfec- 
tion, Nurse,  etc. 


RECORDS  and  reports,  48-58 
Registration  of  cases,  cards  for, 

116;  laws  for,  76,    111-113; 

value  of,  114-115 
Relief,  conditional,  231;  not  to 

be  given  by  nurse,  234;  ob- 


tained by  nurse,  143,  210, 
245-246,  257;  proper  use  of, 
248-249;  rules  for  agents  and 
nurses,  237-241;  withdrawal 
of,  248;  see  also  Nurse, 
Co-operation,  Patient 
Reporting  cases  to  the  Health 
Department,  7,  56-59,  171, 
205-207 


S 


SALARY  of  tuberculosis  nurse, 
20-22,  24 

Sanatorium,  outfit  for,  211- 
212;  value  of,  208-209,  213 

Segregation,  4-5,  218-220, 
223-229 

Sick  leave,  26-28 

Skin  test,  no 

Social  agents  and  workers,  35- 
36,  62,  66-67,  165,  234-239 

Sputum,  cups,  42-43;  disposal 
of,  128-130;  examination  of, 
9,  40,  107-108;  see  also  un- 
der Infection  and  Instruction 

Sterilization,  see  under  Disin- 
fection 

Superintendent  of  nurses,  13, 
15,  24.  59-6o,  116 

Supplies,  nursing,  46;  pro- 
phylactic, 42-45,  76-77»  J33 


TESTS,  tuberculin,  no-ill 
Tuberculin  classes,  196-197 
Tuberculosis,  abolition  of,  223, 
283-284;  arrest  of,  125-126; 
campaign  against,  1-6,  285- 
286;  character  of,  79;  cure, 
2-4,  125,  208-209;  deaths 
from,  283;  difficulties  in 
dealing  with,  79-82,  85-86; 
municipal  control  of,  85-86; 
number  of  cases  in  given 
community,  estimate  of,  63; 
see  also  Bacilli,  Infection, 
Prevention,  Poverty 


292 


Index 


Tuberculosis  Division,  see  un- 
der Baltimore,  Health  Depart- 
ment of 

U 

UNIFORMS,  28-29 
V 

VACATIONS     for     tuberculosis 

nurses,  26 
Visiting  list,  63-66 
Visiting  Nurse  Association,  8, 


9;     see  also  under  Baltimore 
and  Co-operation 
Visits  by   tuberculosis   nurse, 
36-38 

W 

WARDS,  special,  for  tuberculo- 
sis patients,  218-220 
Windows    in    patient's    room, 

137,  H4 

Work  done  by  tuberculous 
patients:  "light  work,"  215; 
outdoor,  216,  see  also  un- 
der Infection  and  Patients 


A 

Medical  Dictionary 
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Giving:  the  Definition,  Pronunciation,  and  Derivation 

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arranged  with  special  reference  to 

use  by  the  nursing  profession 

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Author,  with    Anna    Caroline    Maxwell,   of    "Practical 

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New  York  London 


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